When assessing pain, we often ask patients to assign it a number between 0 and 10. Asking about the effect of pain on behavior and functional status can often give us a more meaningful understanding.
Lifelong Learning in Clinical Excellence | March 8, 2022 | 3 min read
By Brian Lee, MD, PhD, Johns Hopkins Medicine, David Madder, DO, Johns Hopkins Medicine
“TWELVE, my pain is a 12!” our patient said.
This isn’t an uncommon response when asked about the intensity of pain on a scale from 0 to 10. We’ve found that the way we ask patients about their pain can make a big difference in what number they report. For example, defining pain intensity by its impact on behavior and functional status can prevent us from having to interpret reports of “12 out of 10,” and get a more meaningful picture of it.
Pain can be assessed through a variety of methods including unidimensional scales, like the numerical rating scale (NRS) which rates pain from 0 (“no pain”) to 10 (“worst pain imaginable.”) However, the perception of pain is colored by many factors, such as mood, anxiety, or feelings of frustration and helplessness. We’ve also wondered if some patients feel they must convince their clinicians of the reality and urgency of their pain, especially amid the increasing public awareness of opioid overuse. Regardless of the cause, such reports can limit the NRS in accurately and reliably evaluating pain intensity, especially when tailoring management over time.
One approach to addressing this limitation is to present anchors, or hypothetical scenarios of concrete painful events, like, “Imagine a car door slamming into your fingers,” before asking the patient to rate their pain. Taken a step further, each level of pain can be defined by specific descriptors or criteria, as is the case with the Defense and Veterans Pain Rating Scale (DVPRS).
We’ve been adopting this strategy and asking patients to define their pain by its impact on their work, self-care, and activities of daily living (ADLs). Clarifying patient reports with such criteria requires some added time. However, it gives us higher confidence in knowing what an “8 out of 10” means, in a sense that’s more comparable between different patients, and in tracking changes in intensity over time. We therefore try to consistently elicit more descriptive reports like, “8 out of 10 pain, limiting walking or getting dressed.”
Here are two helpful tips when asking about pain intensity:
1. Define pain intensity by specific and consistent criteria.
For example, you can define “10 out of 10” as: “Pain so severe that you passed out,” instead of, “The worst pain imaginable,” given the wide variability in perception, sensitivity, and tolerance of pain.
2. Use criteria that capture the impact of pain on behavior or functional status.
For example, you can define “8 out of 10” as limiting the ability to move around, or a “7 out of 10” as intense enough to miss work and have trouble driving.
Of course, there are limitations to this approach, due to individual differences in baseline function. For example, the 7/10 criteria regarding work may be less clear depending on the patient’s line of work and baseline abilities or limitations and would require a more general interpretation of significant functional change. However, this strategy is worth the added time it takes, in order to provide more accurate and reliable reports of pain, and to frame these reports in the overall impact on a patient’s daily life.
Here’s an example pain scale:
10. You pass out from the pain.
9. You almost pass out, and someone else has to get help.
8. You have difficulty with basic activities, such as walking or getting dressed.
7. You have difficulty with more complex activities, such as shopping or driving. You miss work.
6. You do some activities but cancel or avoid scheduling others.
5. You move more carefully and slowly than usual but you can still do everything you want to do.
4. You feel pain constantly. Others notice that something is wrong.
3. You can temporarily forget the pain. Your concentration and/or sleep may be interrupted.
2. You have to think about the pain to feel it.
1. You have to do something to cause the pain in order to feel it.
0. You feel no pain.
This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.