Why Words Help More Than Numbers When Describing Pain
The most accurate measurement of pain may be what it prevents your patients from doing. What pain “steals” from patients’ lives is often harder for them to handle than the pain itself.
I overheard a conversation recently among three friends talking about their medical issues. One of them suffered from chronic pain and was describing how annoying the pain scale rating is. “I just say 4 every time they ask. It’s just easier.”
The numeric pain scale is a common tool used to assess the pain level of patients. However, trying to accurately assess pain by quantity remains an elusive and difficult task for both healthcare providers and patients. The scale forces patients to place a standard measurable quantity on a physical sensation that differs in each individual. Simply, pain is subjective.
When explained, patients are asked to think of the worst pain of their life and assign it a 10. However, a 10 for one person can be 4 for another and vice versa. For example, a person suffering from chronic pain who says “4” may be an intolerable pain level for someone else. But, that doesn’t mean that a 4 is not that painful for the chronic pain patient or doesn’t need different treatment. You must dive deep into your patient’s situation to find out what constitutes a “4” to them, regardless of what the pain scale suggests a “4” means.
Using language is a much better solution for both physician and patient. The following four questions may not only give you a better indication of a patient’s pain, but also foster a more empathetic, trusting and communicative patient/physician relationship.
Using words instead of numbers gives patients the ability to describe their pain precisely and provide more specificity. These patient-centered measurements allow the physician to decide on a course of treatment in a quicker and much more logical and effective way. The questions also provide better data to use when assessing how well a treatment is working.
1. Can you think of a memory that involved pain?
You may need to expand upon this to patients, such as asking them to think of a time when they experienced what they consider pain so severe they could not function. This may include more than one episode of pain or types of pain. Allow them to think of more than one example.
This could be anything from a car accident to kidney stones to post-surgical pain or a migraine. These examples provide context for them to consider how their current pain compares to that pain, both in type and severity. Though their current type of pain may feel different, the level to which it is causing suffering and loss of function can become more measurable and meaningful when given this context.
2. I want you to be very descriptive. Can you use a metaphor to describe your pain?
Patients also may not be used to giving descriptions of pain. Help them by giving them metaphor examples for pain: “My pain is a hot poker stabbing me in the side.” Or, ask the following list of questions, which may prompt them to be more descriptive. Each patient’s descriptions may provide you with new, insightful questions to ask the patient and your other patients.
- Does it burn?
- Does it ache?
- Is it electric?
- Is it a stabbing feeling?
- Does it tingle?
- Is it painfully numb?
- Does it radiate outward and how far?
- Does it move around and to where?
- Does it hurt more in one area than another?
- Is it dull and diffuse and hard to define?
- Are there times of the day or night when it hurts more?
- Does moving a certain way make your pain worse? Which way? (Let them know they don’t need to induce the pain, just describe the movement.)
- Does moving a certain way make your pain better? Can you show me?
- Does the pain get worse if you touch that area? Where? Lightly or do you have to press harder?
3. Can you describe how your pain behaves as you go about a routine day?
You want to look for trends over time and how well (or not well) they are able to function with their pain, and during what kinds of activities. Some patients may do better imagining their pain as separate from them, such as a separate entity tied to them that reacts to what they do or don’t do – what is the pain doing while they are performing their daily activities? This exercise may allow them to focus more on the behavior of the pain itself in very specific ways versus, “I hurt all day.” This list is a general example and will change with each patient.
- When is your pain the worst during the day? Is that consistent for most days?
- How is your pain when you walk?
- How is your pain when you exercise?
- How is your pain when you are playing a sport or game?
- Does your pain react to certain stimuli?
- How is your pain when you sit? What about for a prolonged period of time?
- Do you have pain that wakes you up at night? How often? Does it feel different than the daytime pain? In what way (go back to the description of types of pain here)?
4. Can you describe how you function, instead of how you feel?
Ask your patient to be very clear about how their pain interferes with or impairs or prevents daily activities, such as:
- Getting out of bed
- Getting dressed
- Personal hygiene
- Cooking meals
- Feeling fatigued and when
- Socializing (they may no longer enjoy going out with friends or visiting family)
- Working and/or job performance
- Household chores like cleaning
- Running errands
- Exercising, especially if they had an exercise routine prior to the pain
- Taking care of children’s needs
- Conversing with another person
- Understanding directions
- Watching television (can they focus on it?)
Thinking about how a patient functions when they don’t have pain versus when they do is a key component of pain. Pain alters behavior, sometimes drastically. How it is altering behavior can tell you quite a bit. In fact, the most accurate measurement of pain may be what it prevents your patients from doing. What pain “steals” from patients’ lives is often harder for them to handle than the pain itself. This kind of function questioning can tell you when you need to add in another treatment team member, such as a therapist.
For example, if a patient was an avid runner and running gave them joy, but pain makes it impossible for them to run, you now have insight into not only just how much pain your patient is in, but also the emotional toll it is taking on them. What if their pain even prevents them from talking? The social isolation can be devastating. Even if you cannot medically get the pain to resolve, you may be able to create a plan with your patient designed to work around the pain instead of trying to make it go away.
5. Will you please share your treatment history?
This line of questioning is pretty standard; however, the more detail you can add to it, the better your understanding will be of your patient’s pain level and condition.
- Give me a history of this pain. How long have you had it? When did it start? Where? Did it get worse over time or better?
- Where is the pain located?
- What aggravates your pain?
- What helps relieve your pain? Heat? Cold? Stretching? Sleep?
- Have you sought other pain treatments? (Acupuncture, massage, homeopathy, medications)
- Were any of these other pain treatments effective? Was the effect permanent or short-term? For how long?
6. Do you have a family history of sensitivity to pain?
Much of a person’s pain sensitivity is inherited. If their parents or siblings are highly sensitive to pain, it’s likely your patient may be as well.
7. Can you draw the pain for me?
Finally, sometimes even words fail us all when trying to describe pain. Not everything tastes like chicken, and not all pain has a verbal description. Or, when in pain, especially great pain, getting your brain to function enough to describe pain may not be possible.
Have black and white handouts on hand of the whole body and specific body areas or parts. Offer your patient the appropriate handout with some colored markers or crayons and ask them to draw the pain. Drawing a representation of pain may be easier for some patients than the frustration of trying to remember specifics and describe them.
You can still use the questions above, but with the handouts. For example:
- Can you draw how the pain feels to you right now?
- What about when you first wake up?
- How is it when you take medication?
Perhaps bright red pain changes to pink. Perhaps the lines of shooting pain get shorter or longer and extend into different areas. They could draw lightning bolts or Xs.
The handouts don’t have to just be for people who would prefer to draw their pain. Offer them to all your patients. The more content you can collect from your patient, the better understanding you will have of their pain and how best to treat it.
You may still wish to use the pain scale in conjunction with these questions. Using it along with detailed questioning may give you great insight into whether or not using the scale is useful with each patient. The more data you have, the better you can accurately determine a patient’s individual pain level.