Pros and Cons of Assessing Patient Pain Levels Through 1 to 10 Scales

The Fifth Vital Sign: Pain, quantity and quality

"Pain scores are sometimes regarded as the Fifth Vital Sign." (1)

Monitoring vital signs are important in patient assessment and evaluation, diagnosis and treatment, but it is difficult to assess a patient's pain level. Accurate assessment is necessary, because pain management is an essential part of a patient's medical treatment and nursing care. In pain management, there have been numerous attempts to measure pain or the degree of pain that a person experiences, using pain scales. There are pros and cons to using these.

What is a pain scale?

"A pain scale measures a patient's pain intensity or other features. Pain scales are based upon self-report, observational (behavioral), or physiological data. Self-report is considered primary and should be obtained if possible. Pain scales are available for neonates, infants, children, adolescents, adults, senior, and persons whose communication is impaired." (2)

Self-reporting pain means that a patient can assess his or own pain subjectively and report it, based on a scale of 1 to 10. This has limitations, but remains the primary mode of pain assessment and evaluation. Where communication on a subjective level in not possible, observation (behavioral) or physiological data must suffice.

Is it a matter or either one or the other?

In 1968, Margo McCaffery, suggested that "Pain is whatever the experiencing person says it is, existing wherever he says it does," (3)

This is assessing pain subjectively or as a patient would perceive it, himself. It opens a door which allows the 

patient to use a subjective pain scale (from 1 to 10), to report his or her level of pain to nurses and doctors, which does have some merit.

There are some drawbacks. Using only a pain scale of 1 to 10 or reporting pain based strictly on numbers, in conjunction with this definition, does not include the reporting of pain by those who have limited communication skills or by those who may not understand how to use a pain scale.

For example, a person who is mentally disabled may not be able to state that he has a pain level of 5 or 8. An infant or small child would not be able to express his or her pain in terms of actual numbers, either. Nor does it allow for those who are restricted by their lack of communication skills or inability to communicate, for instance, someone who is semi-conscious.

The International Association for the Study of Pain (IASP) defines pain from a scientific and clinical perspective, stating pain is "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage." (4)

A subjective analysis of a patient's own pain might include only that which is an unpleasant sensory and emotional experience. Unfortunately, using only a subjective numeric pain scale to report pain may not include the potential tissue damage that is occurring or an appropriate description by the patient, even when it describes an unpleasant sensory or emotional experience. .

Tissue damage can often occur without any awareness of pain. A patient can also experience a relatively low level of pain and be unaware that there is tissue damage occurring. For example, an elderly diabetic may do damage to his or her feet by wearing improper footwear and may not be aware of it, until significant pain is experienced.

There are instances when the patient is aware of damage that is happening, but is unable to report it, because of the limitations of reporting pain on a scale of 1 to 10, which does not express anything other than a numeric level of pain. It excludes the patient's observations about the extent of tissue damage that is taking place. By the time a patient experiences severe pain and expresses it as a 10, it may be too late, as the damage may already be permanent.

Note this quotation with reference to quantity of pain.

"Many attempts have been made to create a pain scale that can be used to quantify pain for instance on a numeric scale that ranges from 0 to 10 points. In this scale, zero would be no pain at all and ten would be the worst pain imaginable." (5)

The difficulty lies in the reality that this is limited to quantity of pain and does not address the quality of pain experienced by a patient. At the same time, the numeric pain scale does serve a purpose.

"The purpose of these scales is to monitor an individual's pain over time, allowing caregivers to see how a patient responds to therapy for example. Accurate quantification can allow researchers to compare results between groups of patients." (6)

In other words, if a patient states that he has a pain level of 8 after treatment with an appropriate pain medication, he might report a pain level of 3. The pain management has been effective, at least for a time.

There are tests that make allowances for the use of subjective numeric pain scales, as well as include a descriptive interpretation of pain.

For example, "the McGill Pain questionnaire consists primarily of 3 major classes of word descriptors - sensory, affective and evaluative - that are used by patients to specify subjective pain experience." (7)

Pain assessment and subsequent pain management has to include both the quantity and quality of pain. It is not sufficient just to assign an arbitrary number, as a subjective designation of the patient's level of pain. The quality of pain is important, too. Other definitions of pain may enable pain assessment, in other ways.

Objectifying the patient's pain, allows doctors, nurses and other health care professionals to assess, evaluate, diagnose and treat their patient's pain more effectively. Pain management with quantity and quality, extends beyond the level that medical personal are able to achieve for patients who only interpret their own pain subjectively and numerically.

For effective pain management, observational (behavioral) or physiological data must be included. For example, an infant's facial grimace gives evidence of pain. So does a small child's reluctance to move a fractured limb.

In other words, nurses and doctor must always assess patients objectively and physiologically for pain, even when a patient is using a subjective pain scale from 0 to 10 for his or her pain management.

(1) http://en.wikipedia.org/wiki/Pain_scale

(2) Ibid.

(3) http://en.wikipedia.org/wiki/Pain

(4) Ibid.

(5) http://en.wikipedia.org/wiki/Pain#The_Dimensions_of_Pain

(6) Ibid.

(7) Melzack, Ronald, The McGill Pain Questionnaire: Major properties and scoring methods, Volume 1, Issue 3, September, 1975, p277-299