{"id":17822,"date":"2018-10-16T12:22:54","date_gmt":"2018-10-16T17:22:54","guid":{"rendered":"http:\/\/thepapergown.zocdoc.com\/?p=17822"},"modified":"2023-03-03T15:05:18","modified_gmt":"2023-03-03T20:05:18","slug":"pain-scale","status":"publish","type":"post","link":"https:\/\/www.zocdoc.com\/blog\/healthcare-trends\/pain-scale\/","title":{"rendered":"Is It Time to Change the Way We Talk About Pain?"},"content":{"rendered":"

Sitting on the therapy table, with my legs stretched out and an ice pack wrapped around each knee, I told my amiable physical therapist Jeff all about my history of knee pain. I brought up the February run that set off the pain, recalled prior stints in PT and rattled off a list of treatments I\u2019d tried. I told him that both knees hurt, but rarely at the same time, and regaled him with my journey through arch support sneakers and drugstore knee braces. <\/span><\/p>\n

But when Jeff asked me about the pain itself, I had less to say. On a scale of 1 to 10, the pain maxed out at a\u2026 nine? A seven? I wasn\u2019t sure if it was dull or sharp, or both or neither. All I really knew was that my knees hurt more than a set of 31-year-old joints ought to.<\/span><\/p>\n

As someone who enjoys nothing more than rearranging words on a page, and will always defend the use of a sentence over an emoji, I felt like language had let me down. <\/span><\/p>\n

Eventually, I just looked at Jeff and shrugged.<\/span><\/p>\n

\n

Pain is <\/span>the most common reason<\/span><\/a> people enter the healthcare system. It\u2019s also a private, subjective experience that’s notoriously hard to communicate. For decades, doctors have primarily assessed pain by asking patients to rate pain intensity on a numerical scale and describe how it feels in words. <\/span><\/p>\n

The fact that these assessment methods don\u2019t work very well, particularly for patients who are young or face language or literacy barriers, is well-documented in studies and widely recognized by experts. What\u2019s less clear is why we\u2019re still relying on them. Some researchers doubt we can do much better until we have technology advanced enough to measure pain directly, but Charles Jonassaint<\/a>, a clinical health psychologist and professor at the University of Pittsburgh School of Medicine, believes we\u2019re just stuck in a holding pattern. Earlier this year, Jonassaint and colleagues introduced an app that lets patients literally see their pain in a new way.<\/span><\/p>\n

\u201cWe\u2019ve been asking patients to use the 1 to 10 scale or describe their pain for so long that I think it can be hard to conceptualize anything different,\u201d Jonassaint says, \u201cbut there\u2019s no reason we can\u2019t move away from these same tired ideas.\u201d<\/span><\/p>\n

Pain points<\/h2>\n

Pain is the primary complaint for more than 80 percent of medical appointments. That figure accounts for <\/span>at least 116 million Americans<\/span><\/a> with longer-term chronic pain, sometimes caused by chronic conditions such as fibromyalgia, arthritis, Lyme disease and multiple sclerosis. It also includes all the short-term (or acute) pain \u2014 broken ankles, torn ACLs, incapacitating stomach aches \u2014 that brings patients into primary care offices, emergency departments and urgent care centers on a daily basis.<\/span><\/p>\n

Much of the time, research suggests, attempts to communicate pain are a two-sided struggle. In studies, both doctors and <\/span>patients<\/span><\/a> have described discussions of pain as <\/span>difficult<\/span><\/a>, <\/span>frustrating<\/span><\/a> and time-consuming.<\/span> In<\/span> one study<\/span><\/a>, 76 percent of physicians identified poor pain communication and assessment as the greatest barrier to successful pain management. Experts even believe that the opioid crisis stems at least in part from poor pain communication. <\/span><\/p>\n

Back in 1996, the American Pain Society launched the “<\/span>pain as the fifth vital sign<\/span><\/a>” <\/span>campaign<\/span>, with the goal of making pain assessments a standard measure of patient wellbeing during every medical visit. The initiative was forward-thinking, but the recommended method for assessing pain, a 0 to 10 rating, was more of the same.<\/span><\/p>\n

A history of scales and words<\/h2>\n

Pain can manifest with physical symptoms, like bruising and swelling, from which doctors can extract diagnostic information. But because outward signs can be deceiving, and some pain only wreaks invisible havoc, doctors also rely on self-report, i.e., what patients say about their pain. This wasn\u2019t always the norm, according to <\/span>Amanda C. Williams<\/a>, a health psychologist at University College London who studies pain. <\/span>Back in the 1950s and \u201860s, doctors in clinical pain medicine trials measured pain on patients\u2019 behalf, without their input. \u201cThe context of just being asked about pain makes a big difference,\u201d Williams says. \u201cClinicians tend to discount patients\u2019 pain, particularly high levels of pain, and particularly in women, ethnic minorities, the very young and very old, among other groups.\u201d<\/span><\/p>\n

Today, doctors usually ask patients to self-report their pain in two ways.<\/span><\/p>\n

First, they ask patients to rate their pain on some type of one-dimensional scale. The most famous one is the ubiquitous 0 to 10 scale, where numerical ratings correspond to mild (1 to 3), moderate (4 to 6) or severe (7 to 10) pain. There are also non-numerical scales: Word scales might range from \u201cno pain\u201d to \u201cworst pain possible,\u201d while visual analogue scales use symbols or pictures.<\/span><\/p>\n

Doctors can collect scale ratings informally, but they can also use standardized assessment tools, most of which have been around for a while. <\/span>The Wong-Baker Faces Pain Rating Scale<\/span><\/a>, with its sequence of happy to sad cartoon faces, has been hanging in every pediatrician\u2019s office since the early 1980s. <\/span>The Brief Pain Inventory<\/span><\/a>, a short questionnaire with multiple scales, was created for adult cancer patients in 1983.<\/span><\/p>\n

\"pain
Wikimedia Commons<\/figcaption><\/figure>\n


\nPain scales are supposed to be a quick, straightforward gauge of pain intensity. But they yield information with no objective meaning; ratings are influenced by various factors, including how sensitive patients are to pain and how likely they are to catastrophize or minimize their suffering. And by reducing a complex internal experience to a single value, these scales often have the opposite-than-intended effect, leaving patients confused and delaying proper diagnosis. <\/span><\/p>\n

\u201cYounger children just tend to choose the smiley face because they like it,\u201d Williams says, \u201ceven when they have a lot of pain.\u201d<\/span><\/p>\n

Scales aren\u2019t a reliable way to measure relative changes in the same person\u2019s pain over time, either. \u201cI have some patients,\u201d Jonassaint says, \u201cwho, when they\u2019re in the hospital getting pain treatment, I\u2019ll ask, \u2018What\u2019s your pain?\u2019 and they\u2019ll say, \u2018Oh, it\u2019s an eight,\u2019 and then after another dose of pain treatment, they\u2019ll still say it\u2019s an eight, and we almost get into a process of these pain ratings becoming automatic.\u201d<\/span><\/p>\n

Second, doctors often ask patients to describe how their pain feels. Pain language was systematized in 1970 with the introduction of the <\/span>McGill Pain Questionnaire<\/span><\/a>, but research suggests that words like dull, sharp, splitting, lacerating and throbbing aren\u2019t actually that helpful. In <\/span>one 1992 study<\/span><\/a>, patients tried to match different types of pain with the most appropriate adjective, and ended up choosing an average of 10 types of pain per adjective. <\/span><\/p>\n

Even with a rich, nimble vocabulary, it can be tough to describe pain with satisfactory nuance or precision. In her <\/span>1926 essay \u201cOn Being Ill,\u201d<\/span><\/a> Virginia Woolf famously noted the paucity of pain descriptions in literature: \u201cThe merest schoolgirl, when she falls in love, has Shakespeare or Keats to speak her mind for her; but let a sufferer try to describe a pain in his head to a doctor and language at once runs dry.\u201d<\/span><\/p>\n

While pain assessments could be frustrating and unproductive for anyone with sickle cell disease, the process disproportionately affected patients from underserved communities.<\/span><\/p><\/blockquote>\n

The shortcomings of pain descriptions are especially pronounced for children, as well as patients who have low literacy or don\u2019t speak the same language as their doctors. While translation might seem like an obvious way to bridge a language gap, research suggests pain words are somewhat <\/span>culture-dependent<\/span><\/a>. <\/span>One 2016 study<\/span><\/a> on musculoskeletal pain found that Nepalese patients had no comparable word for \u201cachy,\u201d a staple pain descriptor in the U.S.<\/span><\/p>\n

Ultimately, though,<\/span> doctors may not even take patients\u2019 descriptions into consideration. \u201cThe sense I get from speaking to dozens of physicians, nurses and physician assistants,\u201d Jonassaint says, \u201cis that providers don\u2019t care about how your pain feels. They just want to know whether you need some type of pain relief or if there is a more significant underlying issue that needs to be addressed. Telling your doctor the pain is aching versus burning typically doesn\u2019t help because those descriptors have not been closely linked to any medical outcomes. So for providers, it\u2019s often \u2018who cares.\u201d\u2019<\/span><\/p>\n

Touch-screen upgrades<\/h2>\n

There are newer pain assessment tools available, including a number of apps, like <\/span>Catch My Pain<\/span><\/a>. But most of them are still rooted in the same methods as their pen-and-paper forebears \u2014 scales and pain words, with a touch-screen upgrade. <\/span><\/p>\n

\u201cWith most of these apps,\u201d Williams says, \u201ceither they look like the old paper-and-pencil things, and they\u2019ve just been transferred to a screen, developed by clinicians with too little technical help, or they\u2019re very whizzy and user-friendly but they run short of clinical utility and meaning.\u201d<\/span><\/p>\n

Jonassaint doesn\u2019t see the point of repackaging old concepts. That\u2019s why he, along with a team of doctors, programmers and scientists from the University of Pittsburgh, Carnegie Mellon University and Duke University, developed Painimation, an app that translates pain into abstract animations. <\/span><\/p>\n

Jonassaint\u2019s pain communication work is an offshoot of his primary clinical focus, sickle cell disease, a genetic condition with chronic pain as a hallmark symptom. Sickle cell patients, Jonassaint says, exemplify the impact of healthcare disparities. He noticed that while pain assessments could be frustrating and unproductive for anyone with sickle cell disease, the process disproportionately affected patients from underserved communities. So Jonassaint and his team set out to create an assessment tool that any patient could use, regardless of their age, native language, literacy level or comfort complaining to doctors. <\/span><\/p>\n

They introduced a trial version of Painimation in June, after testing the app in a study of 170 patients at the University of Pittsburgh Medical Center pain clinic. The study results were <\/span>published<\/span><\/a> in August in the <\/span>Journal of Medical Internet Research<\/span><\/i>.<\/span><\/p>\n