Numbers Don't Tell the Whole Story: Experts Say Better Pain Assessment Measures Needed

Accurately measuring pain has been the subject of some debate ever since the American Medical Association recommended (in June 2016) that pain no longer be regarded as the "fifth vital sign". Here, a pain control specialist and the leader of a patient pain advocacy group share views on how to best measure a patient's pain.

The notion of pain as the fifth vital sign—alongside blood pressure, heart rate, respiratory rate, and temperature—was first recognized in the 1990s. This designation, coupled with patient satisfaction surveys that focus on how much a patient’s pain is relieved, has contributed to an increase in opioid prescriptions, according to the American Medical Association (AMA). As the complex issue of how best to evaluate pain, during what is widely regarded as a serious opioid epidemic, continues to be debated, some experts agree that new tools should be used to more objectively measure patients' pain.

Why Current Pain Scales Aren't Accurate

Pain is typically measured by questionnaires known as pain scales. While there are many pain scales available, the most commonly used ones involve asking patients to rate their pain on a scale from "0" (no pain) to "10" (the worst pain imaginable).

“Pain scales are absolutely unreliable,” said Dimitry Arbuck, MD, president and medical director of the Indiana Polyclinic in Indianapolis, Indiana. “What’s completely missing from pain scales that are typically used, are descriptions. Numbers are subjective, but they’re quick and easy, and that’s why doctors use them.”

He and his team have developed an alternative pain scale. The Indiana Polyclinic Combined Pain Scale which includes descriptions and examples. “These establish some objectivity to an otherwise subjective test,” Dr. Arbuck noted.

The scale combines a rating of pain (along with examples, such as ankle sprain, moderate toothache, day after major surgery, broken leg, or natural childbirth), with an assessment of how a person’s pain impacts their overall daily function (such as whether they can complete daily activities, how often they can leave the house, and how much of the day they are in bed).

The scale also measures anxiety and depression. “Assessing pain without assessing function, depression and anxiety is misleading and partial,” Dr. Arbuck said. “In most cases, pain and suffering come together, which is why you need to consider depression and anxiety along with pain,” he said. “Often, we’ll see someone who comes in with pain complaints of 9-10, and depression and anxiety at 0. As their pain is treated, we see the pain scores go down and the depression and anxiety scores go up. Once their pain is under control, they are more able to appropriately assess their mental distress.”

For patients who chronically use opioids, an addiction evaluation is necessary, Dr. Arbuck said.

Pain's Impact on Daily Function Tells More

Penney Cowan, CEO of the American Chronic Pain Association (ACPA), agrees that currently used pain scales are inadequate. “We don’t know what those scale numbers define,” she says. “Your 5 and my 6 could be totally different. It doesn’t give you a whole lot of information.”

The association has its own Quality of Life Scale, which measures function for people with pain. Unlike most pain scales, a “0” on this scale means a person is non-functioning, while a “10” means the person has a normal quality of life. A “4” on the scale indicates a person struggles but fulfills daily home responsibilities. The person has no outside activity and is not able to work or volunteer. An “8” indicates the person can work/volunteer for at least six hours daily, and has energy to make plans for one evening social activity during the week.

“If you ask any person living with pain, they will say a pain scale is meaningless,” Cowan said. “A functional scale gives a much better sense of the impact pain is having on a person’s life.” She recommends that patients print out the scale and take it with them to doctors’ appointments to help them have a meaningful discussion about their pain.

New App Helps Patients Understand Their Pain

In addition, the ACPA has also developed a new free phone app called the Pain Log, available for Android and iPhone, which allows a person to chart the many factors that affect pain.These include stress, sleep, money worries, fear of pain, sexual activity, appetite, mood, alcohol use, and even weather. The app is designed to help people understand what makes their pain worse, so patients can begin to work on ways to reduce or deal with pain triggers.

People can fill the log out at the end of each day, or several times during the week and print out a report to take to doctor visits. “It can help you talk more openly with your healthcare provider so that together you can find ways to improve your quality of life,” Cowan said.

Updated on: 02/07/17
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