How Much Does It Hurt?

 

Isn't that a great question? How much does it hurt? 

Asking the question assumes that the questioner and the respondent have the same relevant life experiences, the same experiences of pain, and the same mindset about pain. Asking the question assumes that both people are speaking the same language about pain, but they can't be. It is nearly impossible for two people to have experienced the same set of circumstances with an injury, a surgery, a birth, or accident, then experience the same pain throughout, and also use identical language to describe it.

Humans have attempted to bridge the gap though.

Illustrations of faces! Just point to one of the six faces. The Wong-Baker Faces are a solid tool for getting an idea of how young children or preverbal individuals experience pain in a clinical setting. But thinking for a minute about an afternoon with a group of toddlers, think about each child's frame of reference for pain. The skinned knee from falling off of a scooter is the worst pain they have ever experienced because they have so few samples to draw from. Of course it's the worst. If pain is relative to other pain, we can't fault them for choosing the face that represents worst hurt. That is probably true. A tiny bit of TLC and anti-bacterial cartoon character bandage and almost every kid is back on a scooter until the next worst injury. 

The faces scales are also used in pain specialists' offices. Posters with pain scales hang on walls or appear on intake forms for quarterly visits.

"And how is your pain level today?"  Circle the face that applies. There are only 5 choices, but circle the one that applies.

Relative to what? Are we taking an average of the last 89 days since my last appointment? Are we judging pain in context of a daily task or are we motionless sitting in a waiting room with 6 total strangers? 

Without relevant context and examination of overall clinical presentation, the faces are meaningless. Just because I am not sitting atop the papered table dabbing my eyes with a tissue doesn't mean I am not experiencing daily, pervasive, unrelenting pain consistent with the highest available score associated with a two-dimensional illustrated face on the wall. 

Perhaps a person's presentation is a result of coping skills and social expectations that people don't walk around sobbing with extreme emotional lability or they risk exclusion from social circles, leadership positions, friendships, and partnerships. 

The linear illustrations may be a good place to start, but they may be "good" a result of simply not having any other tool to measure something so subjective.

Numbers! Just pick a number for the pain. It sounds so simple.

Given the intensely personal nature of pain, why do medical professionals cling to numerical pain rating (NPR) scores without context as some sort of relevant guidepost in treatment?

11 point NPR scores have been heralded as the fifth vital sign joining body temperature, pulse rate, respiration rate and blood pressure as markers of overall clinical state. Patients rate their pain from 0, lowest pain possible, to 10 which would be the highest pain indicator. But four of these vital signs are far more objective than the fifth one. A person's body temperature is not subjective. They can't report a body temperature relative to how warm or cold they have been in life. They can't report a pulse rate that differs from the one discovered clinically. The same logic applies to breath sounds and rates as well as blood pressure. Those are not typically self-reported whereas numerical pain scores are completely self-assessed and self-declared.

NPR scores, like face illustrations, are not only subjective and relative, but they represent points in time, not averages, or context-based data. 

For example, sitting passively waiting for the physician, an NPR score of 5 would indicate pain levels in the mid-range on the scale. However, during or after physical examination or manipulation, the NPR score may be higher and in fact, remain higher for an extended period of time. Which score should factor into assessment and treatment?

Another example, completing daily living tasks, an NPR score of 4 would indicate pain levels that might be tolerable on the low end of the scale and would allow a patient to complete his/her personal care or daily living tasks successfully with some pain. However, if the patient has modified his or her tasks to exclude elements that are too painful to execute, the NPR score becomes meaningless. Should the patient's self-reported NPR score of 4 factor into assessment and treatment if s/he is only performing activities that hurt less?

How much does it hurt?

Let's try colors.

It hurts MAGENTA, a little yellow, a little blue and a little red.

Yellow for scared that it will never stop.

Blue for sad that it hurts so much.

Red for angry that there aren't better solutions.

It hurts magenta--bright, bold, in your face, magenta.