The Perfect Ten…Point Pain Scale (From 6/16/14)

Of all the questions that we as physical therapists ask our patients, the one I find the most interesting is:
“Can you rate your pain on a scale of one to ten, with one being the least amount of pain, and ten being the most?”

I don’t think there are any clinicians that really love this method of assessing pain. After nearly one hundred years of modern medicine, no one has come up with anything better, but we have come up with lots of variations.

Numeric Pain Rating Scale

Faces Pain Rating Scale

All of these scales attempt to approach the same issue from different angles, but all of them confuse patients and clinicians alike.  Below are some of the answers that I have heard from both patients and clinicians, and all of them demonstrate just how confusing the pain scale can be.

“Do you have a scale that is used for people with high pain tolerance? My pain won’t go on this scale.”
“Well I’d say a 3, but that would be like 9 for anyone else, so should I say 3, or 9?”
“2 and a half”
“It’s not too bad right now, so I guess an 8.”
“Well, a few minutes ago it was a 6, but now it’s a 5.”
“11!”

I hear the above statements, or others like them quite often. Of all the above statements, the one that I find most interesting is the last one.

“11”

The problem here is that 11 is not on the scale, and therefore this number does not mean what many people are trying express when they say it: I have more pain than I ever thought was possible. Because 10 is the maximum amount of pain a person can feel, when any number over 10 is used the scale starts to break down. If you say 11 and then improve to a 10 after treatment, how much pain do you have? The max? Less than the max? This rating makes no sense.

My wife dragged me to see the movie, The Fault in Our Stars, this weekend, and it was actually quite good. Several interesting ideas were expressed about pain in this movie, and it got me to thinking about the “11” rating on the 10 point scale. In the movie, the main character was in severe pain, and when a nurse asked how much, she held up 9 fingers. Later the nurse told her she was brave because she called a 10, a 9. The girl went on to explain that her pain really was a 9, because she was saving her 10. She didn’t want to waste it, when she knew there were certainly greater pains she could experience, than what she currently felt.

This struck a chord with me, and I think gave me a deeper understanding of the pain scale. Essentially, the 10 rating implies that a person is in infinite levels of pain. How much pain is that? It’s infinite. Another idea, expressed by the character in the movie, was that some infinities are larger than others. In the same way, maybe some 10 pains are greater than others, but we would have a great deal of difficulty quantifying them.
Pain is extremely subjective. We cannot compare the pain of one person, to the pain of another, because it is unique to each individual, regardless of the number rating. However, I think it is safe to say that many of us have not truly experienced a 10 pain. Can you imagine an infinite pain? Can you imagine a pain that is beyond all imagination? Maybe a redefinition of the pain scale is necessary, in which a 9 represents the maximum imaginable pain, and 10 represents the unimaginable. I think I will be saving my 10 for now.

Patrick

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