essays on pain assessment

Log in using your username and password

• Search More Search for this keyword Advanced search
• Latest content
• Current issue
• BMJ Journals More You are viewing from: Google Indexer

You are here

• Volume 49, Issue 4

Cripping the pain scale: literary and biomedical narratives of pain assessment

• Article Text
• Article info
• Citation Tools
• Rapid Responses
• Article metrics

• http://orcid.org/0000-0003-3526-3399 Neko Mellor
• School of English , University of Leeds , Leeds , UK
• Correspondence to Neko Mellor, School of English, University of Leeds, Leeds, LS2 9JT, UK; n.mellor1{at}leeds.ac.uk

This article analyses the literary representation of pain scales and assessment in two chronic pain narratives: ‘The Pain Scale’, a lyric essay by Eula Biss, and essays from Sonya Huber’s collection Pain Woman Takes Your Keys, and Other Essays from a Nervous System . Establishing first a brief history of methods attempting to quantify pain before my close reading, I read both Biss’ and Huber’s accounts as performative explorations of the limitations of using linear pain scales for pain which is recursive and enduring. Considering both texts as cripistemologies of chronic pain, my literary analysis attends to their criticism of the pain scale, including its implicit reliance on imagination and memory, and how its unidimensionality and synchronic focus prove inadequate for lasting pain. For Biss, this surfaces as a quiet critique of numbers and a disturbance of their fixity, while Huber’s criticism employs the motif of pain’s legibility across multiple bodies to spell out alternative meanings of chronic pain.

Crucially, this article proposes a crip and embodied approach for reading and responding to accounts of chronic pain’s measurement, including Biss’ and Huber’s literary accounts, and the biomedical account of pains scales which this article reads alongside them. The article’s analysis draws on my personal experience of chronic pain, neurodivergence and disability to demonstrate the generativity of an embodied approach to literary analysis. Rather than bowing to the impulse to impose false coherence on my reading of Biss and Huber, my article foregrounds the impact of the re-reading, misreading, cognitive dissonance and breaks necessitated by chronic pain and processing delays on this analysis. In bringing an ostensibly crip methodology to bear on readings of chronic pain, I hope to invigorate discussions on reading, writing and knowing chronic pain in the critical medical humanities.

• literature and medicine
• Medical humanities
• patient narratives
• literary studies
• Pain management

Data availability statement

No data are available.

https://doi.org/10.1136/medhum-2022-012484

Statistics from Altmetric.com

Request permissions.

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Chronic pain, defined as pain persisting or recurring over 3 months, evades scientific explanation and is stubborn in the face of attempts to eliminate it ( Treede et al . 2015 ). As this article demonstrates, this persistence is evident in biomedical writings which attempt to comprehend pain, and literary narratives which emphasise its resistance to all types of containment. 1 Literary narratives of chronic pain, which chronicle attempts at chronic pain’s enumeration, are the focus of this article’s analysis. Such accounts frequently depict pain assessment as an encounter in which experiences are validated or denied, treatment plans made, and personal support systems called into question. The pain scale, an assessment method in the form of a verbal rating scale or ‘a line that represents the continuum of the [pain] to be rated’, is ubiquitous in the clinic and in literary chronic pain narratives ( McDowell and Newell 1996 , 341). This article analyses the literary representation of pain scales in Biss (2005) and essays from Sonya Huber’s collection Pain Woman Takes your Keys, and Other Essays from a Nervous System ( Huber 2017 ). I consider Biss’ and Huber’s frustration with such scales’ reductive simplification of chronic pain’s complex lived reality alongside readings of biomedical texts about the origins and implementation of pain scales, demonstrating how means of conceptualising and enumerating pain might inadvertently contribute to further suffering ( Levy, Sturgess, and Mills 2018 , 435). I demonstrate how Huber’s and Biss’ appropriation of the pain scales structure foregrounds chronic pain’s resistance to reductive enumeration enacting a criticism of the scales which infuses the impersonal instrument with the authors’ cripistemologies of chronic pain.

This article demonstrates the importance of cripistemological understandings of chronic pain, challenging an existing hierarchy which favours clinical signs and biomedical explanations over bodily epistemologies. The term ‘cripistemology’, coined by Merri Lisa Johnson, captures the flamboyance of claiming ‘crip’, a means of understanding disability beyond and in defiance of medical and social models, and epistemology, suggesting ways of knowing disability ‘around and through’ its lived experience, in excess of medicalised deficit models ( Johnson and McRuer 2014 ). Cripistemology underscores the importance of disabled people’s experiential and bodily knowledge, understandings which have been traditionally denied in favour of medicalised accounts; in so doing, cripistemology can help to ‘situat[e] pain within discursive systems of power and privilege’ to counter reductive simplifications of chronic pain’s complexity ( Patsavas 2014 , 205). In addition, crucial to this article’s crip reading process is Jasbir Puar’s assertion that the word ‘cripistemology’ captures the cripping of knowledge production, ‘a displacement […] of conventional ways of knowing and organizing knowledge’ to make way for crip methodologies ( McRuer and Johnson 2014 , 163–64). This article raises Biss’ and Huber’s accounts of pain assessment, for unspecified chronic pain and rheumatoid arthritis, respectively, to the importance of biomedical accounts on the subject. It bears witness to their expressions of pain and frustrations with assessment, and places their literary narratives in dialogue with biomedical accounts of the pain assessment methods which they critique.

To this end, the article will briefly engage with clinical texts, including Ronald Melzack and Turk (2011) , Pasero and McCaffery (2011) , and research papers on pain scales’ implementation, solidifying the grounds for Huber’s and Biss’ critical appraisal of the pain scale and predicating my literary analysis on an account of the scales’ development and clinical implementation. I demonstrate the generativity of reading literary and biomedical accounts together and of a dialogical understanding of these oft-polarised means of knowing chronic pain, nuancing understandings and approaches to pain, and its assessment in the critical medical humanities.

In so doing, this article builds on existing responses to Elaine Scarry’s thesis that pain is inexpressible due to its inherent resistance to language. 2 In The Body in Pain: The Making and Unmaking of the World , the most well-known text on pain studies in the humanities, Scarry contends that pain enacts a monolithic attack on language, and that another’s pain is always subject to doubt because it is not available for sensory confirmation ( Scarry 1985 , 3). I complicate Scarry’s contention by responding that chronic pain has particular expressive difficulties which differ from the acute pains her text describes, recognising chronic pain as especially resistant to measurement with and communication through pain scales due to their synchronic focus and failure to address chronic pain’s enduring, complex lived reality. I respond to Scarry by claiming that chronic pain’s expressive difficulties do not mean it is unshareable. Instead, Biss’ and Huber’s literary responses to the pain scale, especially in those moments where language cracks under the weight of pain, render their pain shareable and recognisable with my own experiences of chronic pain, which I treat as formative for this article’s analytical work. For me, pain’s attack on language and its resultant fragmentation of syntax and meaning are especially evocative of the onslaught of a pain flare and the strain of living under it.

My account of the pain scale’s mechanisms and structure, drawn from biomedical texts on pain assessment, foregrounds how ‘The Pain Scale’ and Pain Woman appropriate the pain scale’s form to visibly critique its reductive treatment of chronic pain. The scale, which at best yields a snapshot analysis of pain, is incompatible with pain which is enduring or recursive. Both types of narratives, literary and biomedical, underscore the difficulty associated with the task of pain’s enumeration; in response, Biss disturbs the alleged fixity of points on the scale through a quiet critique of numbers and their imprecise meanings, while Huber constructs a new personal scale and imagines pain as a legible entity spelled out across multiple bodies. The scale’s implicit reliance on memory and imagination—the inevitable result of the wording of anchors, the verbal labels which demarcate the scale’s discrete range—demonstrably distorts responses and can vastly alter the nature or extent of treatment offered. Guidance for using such scales can betray a tendency towards Cartesian dualism, which is prevalent in pain discourses elsewhere and overlooks the fact that physical pain can be experienced alongside, because of, or through negative affects. Ultimately, the authors maintain that chronic pain can provide no easy answer to the questions asked by the pain scale, sustaining its questions through the cyclical and associative momentum of the lyric essay form.

Finally, this article establishes and demonstrates a methodology for engaging with narratives of chronic pain which blends reading with my disabilities and an attunement to texts’ material and affective dimensions. My engagement with Biss, Huber and the other authors on pain scales is cripistemologically inflected, and draws on my experience of chronic pain, disability and neurodivergence. I explicitly validate and include these experiences as they come to me in reading, challenging the ableism inherent in trying to obscure them. Indeed, brain fog and neurodiverse ‘sitpoints’ (a term first used by Rosemary Garland Thomson to ‘cal[l] attention to the normative assumption that one perceives the world from standing rather than sitting’ and which resonates powerfully with my experience of postural orthostatic tachycardia syndrome (PoTS)) are among perspectives contemporary disability studies has come to value for producing queer, twisted readings, bending source materials out of shape and eliciting new approaches to familiar concepts ( Garland‐Thomson 2005 , 1570). 3 I build on the work of crip writers such as Ann Cvetkovich, for whom impasse, which can arise from altered cognitive states, is cast in terms of its positive and productive value, considering it ‘a state of both stuckness and potential’ which can be freed up when ‘alternative forms of writing can spring them loose as foundations for innovative thought’ ( Cvetkovich 2012 , 21 and 81). Furthermore, my work aligns with Mel Chen’s validation of brain fog as cripistemology, challenging its ‘active suppression’ in academia where it might ‘represen[t] the near unthinkable’ instead of something to channel for academic enquiry ( Chen 2014 , 171 and 177). My article builds on their vocabularies and enfolds stuckness, impasse, brain fog and other cognitive states arising from my disability into this article’s analytical work.

In my experience, ‘stuckness’, ‘impasse’ and ‘brain fog’ often coincide with fatigue, pain, nausea, dissociation, dyspraxia, Irlen syndrome and sensory overload. 4 Too often, these cognitive and physical states feel de-creative; far from providing access to crip analysis, they make me feel something which often fails to materialise as thought. Sometimes, dissociation or necessary breaks in reading result in incomplete, disjointed conclusions, or a text’s meaning resonating in a body part rather than in my brain. In spite of (or perhaps because of) this challenge to my working memory and coherence, I experience an amplification of the material qualities of the texts with which I work—the weight and size of a text, the thumbprints on a page, or the creases in a book’s spine speak as loudly to me as the ideas the texts contain, seeming to pursue their own trajectories and forcing me to join in. As such, my methodology entails the explicit acknowledgement of these challenges and intensities, and reproduces my work of reading and re-reading, allowing for interpretative mistakes, revisions and circling back, and attention to the affective dimensions of a text’s material qualities. My analysis considers the appropriateness of crip-materialist engagement for interpreting and reading Biss’ and Huber’s lyric essays, which move associatively and demonstrate their own resistance to linear logic, attending to the disorienting particularities associated with the form. It also asks questions of the coherence achieved by reading such literary accounts alongside biomedical narratives of pain assessment—something which I consider generative for my analysis, even if my brain fog challenges my ability to say why. It is my hope that my methodology for engaging with chronic pain narratives, informed by my own chronic pain and associated difficulties, might invigorate discussion in the medical humanities about non-normative routes to meaning and vouch for the embodied understanding of literary and biomedical texts.

A brief history of pain scales

Before commencing my analysis of pain scale’s literary representations, I wish to briefly outline the scale’s invention, structure and clinical usage. This account, particularly of the scale’s appearance and structure, is instructive for my later reading of Biss’ and Huber’s visible adoption of the pain scale’s form in order to critique it. Likewise, this section contextualises Huber’s and Biss’ discussions of the complexity surrounding the anchor phrases in the scale, which I consider muddle attempts to quantify pain with acts of imagination, memory, and pain’s perplexing subjectivity and messiness. I demonstrate how, at best, the scale yields incomplete information from which to understand the experience of the strange logic and enduring suffering associated with chronic pain, which I demonstrate with reference to my own experience of a pain assessment.

For anyone who has routinely undergone pain assessment, the phrase ‘pain scale’ conjures memories of healthcare professionals asking them to rate pain ‘on a scale of one to ten’, or a printed scale on which to mark where pain lies. Popularised by the rheumatologist EC Huskisson in the 1970s, the Visual Analogue Scale (VAS) is ‘a line [conventionally 10 cm long] that represents the continuum of the symptom to be rated […] marked at each end with labels that indicate the range being considered’ (see figure 1 ) ( McDowell and Newell 1996 , 341). When VAS is used to assess pain, phrases such as ‘no pain’ and ‘pain as bad as it could be’ or ‘worst pain imaginable’ stand at opposite ends of the line, demarcating a discrete range from which patients can rate their pain. Clinicians laud this quantification method because it is cheap, quick and can be followed up with multiple comparative measurements ( McDowell and Newell 1996 , 341).

• Download figure
• Open in new tab
• Download powerpoint

Visual Analogue Scale, showing the anchors ‘No pain’ and ‘Pain as bad as it could possibly be’ (adapted from Pasero and McCaffery 2011 , 55)

Figure 1 testifies to the scale’s simple appearance, but its clarity is undermined by anchor wordings and how these relate to individuals’ pain experiences. Clinicians have shown reticence about anchor wording, stating that ‘No single-word anchor has been identified as being the best one for the number 10 [but they have tried] “worst imaginable pain”, “worst possible pain”, “most intense pain imaginable,” “terrible pain”, and “pain as bad as it can be”’, presenting multiple options which belie the scale’s certainty ( Pasero and McCaffery 2011 , 56). Upper anchors depend implicitly on imagination, memory and interpretation: patients asked to rate pain in relation to the ‘worst imaginable pain’ might compare it to their worst pain memory or treacherous imagined pains—and neither response is contraindicated. Reliance on imagination may distort ratings by intensifying the ‘worst pain’, resulting in inadequate treatment. For chronic pain, drawing from experience, it is easy to understate the intensity of ‘new’ pains, compared with the enduring pains which one abhors and must constantly endure. Anchor wording disturbs the pain scale’s parameters, undermining its reliability and eliciting answers which muddle imagination, memory and subjective measurement.

The origins of pain measurement can be traced to World Wars I and II, when clinical understandings of pain accelerated; physicians could directly observe pain mechanisms in war casualties with serious injuries. Scientists then developed three main strategies to measure the pain experience: psychophysics, questionnaires and pain scales ( Noble et al. 2005 , 14). Despite these developments, the history of pain assessment characterises pain as solitary and ‘always subjective’, resistant to enumeration (International Association for the Study of Pain, IASP 2018 ). IASP echoes the sentiment that pain’s subjectivity remains ‘a central impediment’ to its quantification ( Melzack and Turk 2011 , 4). It is ‘a complex perceptual phenomenon’ which evades communication despite decades of research into enumeration methods ( Melzack and Turk 2011 , 4–5). Similarly, some assert that pain is ‘the most challenging and difficult area of subjective health measurement’, complicated by its multidimensionality, interiority and influence by cultural norms ( McDowell and Newell 1996 , 335). As a chronic pain sufferer, I know first-hand the inexactitude of quantifying enduring pain, and the difficulty of getting others to recognise its chronicity. I contend that chronic pain has more expressive difficulties than acute pain, rendering it especially resistant to enumeration.

Indeed, methods of measuring, writing and talking about pain can have devastating and far-reaching consequences. It is in the wake of the current opioid addiction epidemic that the medical community has addressed the problematic nature of scales. I wish to preface this account of pain scales’ connection with the opioid epidemic by noting that I am not criticising any person whose means of managing pain includes opioids: rather, I wish to establish an account of how language to describe and measure pain, alongside outside forces including pharmaceutical representatives, reimbursement processes and the urgency of palliating pain, has become connected with a spiralling epidemic in which thousands have developed drug dependencies or died. 5 A notable example of the profound impatct of pain’s conceptualisation was its designation as the ‘fifth vital sign’ (5VS), a campaign adopted by US clinicians in the 1990s ( Levy, Sturgess, and Mills 2018 , 435). In 1990, Dr Mitchell Max decried pain medicine’s lack of advancement, issuing the imperative to ‘make pain visible’ by giving all clinicians ‘bedside tools’ for rapid assessment ( David 2017 ). In October 2000, then-US President Bill Clinton designated the 2000s the Decade of Pain Control and Research; this period placed more onus on clinicians to rapidly assess and alleviate pain. Pain was conceptualised as an ’objective measurement of the essential physiological functions of a living organism’, alongside body temperature, blood pressure, pulse and respiration ( Sapra, Malik, and Bhandari 2022 ). Alongside this, clinicians accepted reports that pain patients’ addiction to narcotics was extremely rare ( Porter and Jick 1980 ). The 5VS campaign emphasised monitoring and treating pain quickly, and increased clinicians’ reliance on rating scales to assess and reduce physical suffering.

In other words, the 5VS campaign and resultant over-reliance on pain scales were borne of a desire to alleviate pain. However, their unintended catastrophic consequences include the overprescription and misuse of opioid drugs, addiction and death. The Decade of Pain Control saw clinicians overprescribing narcotic analgesics such as OxyContin to ease pain. Two decades later, 5VS was criticised as a ‘contributo[r] to the opioid crisis’ through its excessive emphasis on relieving pain and opioid overprescription ( Chisholm-Burns et al. 2019 , 424). Clinicians implicated the Numerical Rating Scale as ‘directly contribut[ing] to the prescribed opioid epidemic that America is now experiencing’ ( Levy, Sturgess, and Mills 2018 , 435). The Joint Commission, the US organisation responsible for accrediting healthcare providers, ceased promoting the campaign and instructed clinicians to abandon it. Recognising the harm caused by the scale’s incomplete information, Biss’ narrative, which I examine later, demonstrates doubts about pain scales’ efficacy for capturing enduring pain’s complex experience, articulating concerns shared by the medical community that such scales ‘measure only intensity, [thus] they cannot be viewed as a comprehensive pain assessment’ ( Karcioglu et al. 2018 , 708).

The history of pain scales’ development reveals much about some clinical attitudes towards patients’ attestations of pain; these can prove challenging for patients who, like me, want their pain to be witnessed in the clinic, and for a space to be held to discuss its sensation. Many sources ascribe drug evaluation as the driver for scales’ invention, but I consider that this historical angle inadvertently renders patients’ experiences peripheral, overwriting multidimensional pain experience with enumerative exercises. One history of pain scales emphasises using felt differences to ‘establish the efficacy of analgesics and other therapies’, providing ‘the crucial method by which analgesic therapies can now be evaluated and compared’ ( Noble et al. 2005 , 14 and 15). Another account, which stresses the need for clinicians to codify expressions of pain in a manner suitable for statistical analyses, indicates that the VAS and ‘NPRS (numeric pain rating scales) [are] used to measure pain change’, for instance in the development of narcotics or the assessment of other treatment modalities: rather than viewing the subjective patient report as superfluous or useless, Graham emphasises clinicians’ and researchers’ need for an instrument which renders the pain report useable ( Graham 2015 , 60). However, the use of such scales primarily as ‘means of quantifying patient report, with most designed specifically for RCTs [randomised controlled trials] rather than for clinical care’ seems at odds with my experience of the ubiquity of pain scales in clinical settings ( Graham 2015 , 60–61). I consider that these accounts’ emphasis on metrics subtly overwrites sensation, inadvertently shifting focus from pain towards evaluative discourses about treatment. Perhaps this reflects a limit, whereby pain can only be understood through its conditional relationship to other factors. Though I recognise the centrality of assessing treatment’s efficacy, part of me feels uneasy that these explanations of metrics divert attention from discussions of chronic pain’s experiential reality.

Historical accounts indicate that the relegation of patients’ expression of pain, in favour of objective signs and symptoms, is sometimes driven by scepticism. This is somewhat surprising considering patients were encouraged to express their pain visibly and vocally in the nineteenth and early twentieth-centuries, when an expressive release was deemed physiologically beneficial and diagnostically useful ( Bourke 2014 , 62). Nonetheless, Turk and Melzack report that ‘many clinicians suggest that the report of pain should be ignored’, considered unreliable compared with more ‘objective’ signs ( Melzack and Turk 2011 , 8). This focus on visible signs effectively effaces patients’ rich personal explanation, excluding pain sufferers from analyses of their own pain.

While visible clinical signs are diagnostically important, pain behaviours and facial expressions also have significant implications for pain assessment. The Wong-Baker FACES Scale is one example of the use of facial expressions, although in the form of illustration, in clinics. The FACES Scale features linear drawings of facial expressions, ordered from least to most distressed. Users are expected to identify the facial expression which ‘best illustrates the physical pain that they are experiencing’, while avoiding reading facial expressions for emotion ( Baker and Wong 2016 ). This scale was devised by paediatric clinicians Connie Baker and Donna Wong; working on children’s wards, they observed that ‘children often work through their fears or concerns through play’, but severe illness or injury can prevent this ( Baker and Wong 2016 ). The FACES website details how injured children may have their proclamations of pain disregarded in clinics, and thus receive inadequate pain relief. In response to this, with these children’s help, Wong and Baker developed the FACES Scale.

Wong and Baker showed children six blank circles, asking them ‘to think back to their own experiences and draw facial expressions to show how they had felt when they experienced different levels of pain’. They adapted and arranged them in a sequence of increasing pain from left to right ‘because it consisted with other scales and with English reading’ ( Baker and Wong 2016 ). A copy of the FACES Scale is provided in figure 2 , underneath a conventional NRS, since they sometimes appear together for clarification.

A combined Wong-Baker FACES (FPS-R, faces pain scale - revised) and Numerical Rating Scale.

While I appreciate Wong and Baker’s dedication to relieving injured and sick children’s pain, and the difficulty of developing a method which is adequately informative of the nature and intensity of pain being treated, their website’s usage guidelines betray a tendency towards Cartesian dualism which is prevalent in clinical pain discourses. The authors approve the scale’s use ‘for pain assessment only’, and explicitly ‘do not give permission for use in measuring emotions, mood, comfort, etc’ ( Wong and Baker 2016 ). While I understand the need for such disclaimers, and the reasons why focusing on specific elements of pain might take precedence in a clinical setting, the phrasing ignores the fact that physical pain is frequently experienced alongside, because of, or through negative affects. Further reviews indicate that FACES anchors ‘confound pain measurement with nonnociceptive states’ ( Garra et al . 2013 , 17). Despite a desire to maintain mind/body separation, chronic pain is strongly correlated with anxiety, depression and trauma ( Cosio and Meshreki 2017 ). In my experience, choosing an appropriate facial expression would be difficult: I am no longer able to facially express pains I have had for years, so choosing a face from the scale seems arbitrary. Pain is indissociably linked with emotion, and the distinction between them feels forced: pain and depression ‘exacerbate one another’, causing a vicious cycle of physical and mental anguish ( Cosio and Meshreki 2017 ). Indeed, certain conditions may limit facial expressiveness, masking the urgency of pain or its attendant emotions. I consider that quantifying pain using facial expressions might prove more difficult when pain has been prolonged, treatments ineffectual, and the quotidian existence of pain no longer draws a frown.

Despite the developments in pain measurement I have explored here, chronic pain, its expression and its clinical appraisal remain difficult. While revising this article, I had a hurtful, if elucidating, experience in A&E (Accident & Emergency Department). Sent to hospital by my GP (general practitioner) to X-ray my swollen thumb, a nurse performed my initial assessment. Assessing my hand and wrist, she dismissed my claims that the area had hurt for years. When I attempted to explain that the area was affected by osteoarthritis, she laughed with her colleague, perhaps as I appeared too young. Prising my hand for assessment, she repeatedly yelled ‘you’re stopping me from bending it’ and to ‘stop resisting’, despite my protest that I had never been able to move my hand in that direction. She asked why I had a walking aid; I explained my leg length discrepancy, PoTS and Ehlers-Danlos syndrome to eye-rolls and sighs. I left the nurses and walked to the X-ray department in tears and whispered that I needed to speak with someone in privacy. Two radiographers did all they could to calm me and prevent me from leaving without having my X-ray, explaining, as I had felt all along, that A&E is ill-equipped to recognise and understand the baseline levels, sudden flares and strange logic of chronic pain. Knowing what I do about pain assessment and epistemic invalidation did not make it easier to calm the physical and emotional hurt. Pain assessment in isolation, numbers without context, seem a pale imitation of life with a constant background of pain. Fortunately, many clinicians do what they can to listen to patients and make space for the stories that accompany the numbers. The experience, awful as it was, affirms my thesis that chronic pain has frustrating expressive difficulties, that assessment can be hurtful, and that enduring pain is resistant to the synchronic analysis offered by pain scales.

A crip reading of Eula Biss’ ‘The Pain Scale’

It is exciting to think of the generative capacities of performing crip reading—until it isn’t. Confronted with Eula Biss’ ‘The Pain Scale’, what initially makes it so apparently impenetrable is its spaciousness (see figure 3 ): it is around 20 pages long, constructed from short, spread-out paragraphs, each encased in a bubble of white space. At a glance, there is more white space than text. The piece appeared in The Seneca Review in 2005, but it is still widely circulated as a PDF, with Biss’ original layout intact. As a lyric essay, a hybridised form which borrows from the creative licence of poetry and the sustained thoughtfulness of non-fiction prose, ‘The Pain Scale’ resists being read as one or the other. Each paragraph, immobilised in white space, suggests the succinctness of a haiku or poems by Emily Dickinson, beckoning readers to unfold their densely loaded meaning. I feel disoriented by the text on a visual level: its white spaces and serif font, combined with my dyspraxia and tinted reading glasses, resist an easy reading. Perhaps this is why I do not know where to begin: I see elements of ‘The Pain Scale’ which blend experimental prose and poetry, and fear I’ll misunderstand it. Joe Moran considers that this structure and spacing is as important to the lyric essay as chronology and development are to more conventional narratives; this form instead ‘relies […] on evocative juxtapositions, forcing the reader to make little intellectual and emotional leaps across the white space of the page’ ( Moran 2018 , 1280). Moran’s compulsion is to read across these spaces, to read paragraphs associatively, rather than to fixate on the space itself. It occurs to me that getting stuck in the space is what I am doing wrong.

A double-page section from Eula Biss’ ‘The Pain Scale’ as it originally appeared in The Seneca Review (minus my orange highlights), with numbered arrow at the top.

Biss’ appropriation of its structure infuses the impersonal instrument with the stuff of her personal understanding of pain: half-recalled conversations, associations, questions, hesitations. Her critique of pain scales is also embedded in her text’s material qualities, which mimic the layout of the scale, with numbered arrows at the start of each vignette. The essay is performative: its discussion relies on its adoption of the traditional pain scale’s form. I hold the image of ‘The Pain Scale’ mentally alongside a Numerical Analogue Scale or VAS (see figure 1 ); Biss’ scale overwrites the minimally labelled VAS with important personal details, reformulating the scale from a line, a series of numbers and anchor phrases, to one which accommodates an expanse of thoughts, memories, ideas and associations (see figure 3 ). One might say that, but for the arrows and numbers at the top of each page, Biss’ essay transforms the appearance and mechanism of the pain scale, using its structure as a vehicle for her critique of putting numbers to pain.

Numbers appear frequently, working associatively to enable criticism of pain scales’ reductiveness and imprecision. I read Biss’ disturbances of numbers’ meanings as key to her discussion, opening a space in which her critique of the scale can emerge. But these moments where Biss discusses numbers are scattered throughout the text, cropping up when Biss’ discussion seems to have moved on, making it difficult to analyse their accretive impact. In the essay’s opening paragraphs, Biss queries the use of numbers, particularly zero:

‘The concept of Christ is considerably older than the concept of zero. Both are problematic – both have their fallacies and their immaculate conceptions. But the problem of zero troubles me significantly more than the concept of Christ. […] Zero is not a number. Or at least, it does not behave like a number. It does not add, subtract, or multiply like other numbers. Zero is a number in the way that Christ was a man. Aristotle, for one, did not believe in Zero. (p. 5)

Biss is ‘trouble[d]’ by ‘the concept of zero’ which she aligns with the ‘problematic’ nature of the ‘concept of Christ’ (5); the seemingly calculated enumeration of pain is more an act of faith. ‘Problem’ is a loaded term in Biss’ numerical rhetoric: a problem is an issue, an obstacle, a troubling dilemma. In the context of numbers, however, a problem becomes a puzzle or a question to be answered. Throughout this vignette, Biss is concerned with zero, which ‘does not behave like a number’ and ‘makes some very simple numbers very difficult to solve’. The phrase ‘concept of zero’ almost escapes my notice, but another reading necessitates a closer look. ‘Concept’, a striking noun choice here, transforms the meaning of zero: it is no longer a positivist numerical value, but an abstract entity. Likewise, ‘concept’ reduces Christ from a person and centrepiece of religious beliefs into an idea, a fiction, a way of thinking. Quietly cynical, Biss indicates how ‘zero’, ‘not a number’, is an absolute which ‘is not absolute’ (6); even absolute zero is colder than zero and so ‘There are zeroes beneath zeroes’. The repercussions of this juxtaposition are that when Biss is ‘asked to rate [her] pain from zero to ten’ (5), zero is no longer available, making the ‘simple’ problem of enumerating pain very difficult to solve.

Elsewhere, Biss undercuts numbers’ precision. Also at zero, she asserts that ‘Aristotle, for one, did not believe in Zero’ (5). This sentence contains two numbers, one and zero, although seeing them both requires a perceptual shift. The ‘one’ of ‘for one’ is not a value: Biss shifts it from an exact number to a part of speech, as in the ‘one’ used to introduce opposing lines of argument (as in ‘on the one hand’). This subtle, almost obscured ‘one’ (against the capitalised ‘Zero’) undermines the potency and stability of numbers. Zero and one are held up for discussion, and their lack of fixity gives way to Biss’ lack of confidence in the pain scale.

Later, Biss performs another disturbance of numerical values. At the second point on Biss’ scale, where she contemplates the value of whole numbers and affirms that ‘The devil is in the fractions’ (9), Biss considers that:

Although the distance between one and two is finite, it contains infinite fractions. This could also be said of the distance between my mind and my body. My one and my two. My whole and its parts. (9)

Biss’ ‘one’ and ‘two’, respectively her mind and her body, illustrate the Cartesian dualism prevalent in pain discourses, splitting body and mind on either side of ‘infinite fractions’. But this is strange given Biss’ hesitancy towards such dualism; she is critical of the ‘researcher [who] observed that “hurting” and “feeling” seemed to be synonymous to some children, and is “puzzled by the distinction”’ (13). Trying to reconcile Biss’ exemplification of biomedicine’s chasm between body and mind, and her explicit criticism of such distinction, is tricky; reading in a way which holds both ideas together brings with it feelings of blankness and dissociation. If, in the above quotation, ‘mind’ is ‘one’ and ‘body’ is ‘two’, by process of juxtaposition, then ‘whole’ and ‘parts’ describe a different, unexpected connection between body and mind. If Biss considers her ‘mind’ as the whole, of which her body is a part, then she reverses body and mind’s expected metonymic relationship. Can the mind be the body’s ‘whole’? The association of ‘mind’ with ‘whole’ escapes my notice several times, but Biss’ end-weighting of ‘My whole and its parts’ seems to put a quiet but important question to readers. That Biss critiques the splitting of body and mind is clear, and perhaps the metonymy of ‘mind’/’whole’ references the brain’s centrality to pain.

The discussion of numbers in ‘The Pain Scale’ articulates the complexity of quantifying pain on a scale with confusing anchors. Biss foregrounds the paradox of fixed points’ instability, and their reliance on memory and imagination:

Left alone in the exam room I stare at the pain scale, a simple number line complicated by two phrases. Under zero: “no pain.” Under ten: “the worst pain imaginable.” The worst pain imaginable… Stabbed in the eye with a spoon? Whipped with nettles? Buried under an avalanche of sharp rocks? Impaled with hundreds of nails? Dragged over gravel behind a fast truck? Skinned alive? (11)

Biss negotiates the difficulty of quantifying pain when the scale’s anchors bear no fixed meaning or relation to personal experience; for the rating experience to make sense, ‘A scale of any sort needs fixed points’ (5). She is caught between ‘entertaining the idea that absolutely no pain is not possible’ (5) and trying to understand what the ‘worst pain imaginable’ could mean or look like (11). Her striking imagery, the ‘spoon’ which stabs, ‘nettles’ which whip, the ‘hundreds of nails’ which impale, weaponises everyday objects in the causation of pain. The list’s compounded absurdity emphasises scales’ reliance on limitless and unhelpful acts of imagination. These phrases recall Elaine Scarry’s discussion of weapon metaphors: Biss’ nails, nettles, rocks and gravel, like Scarry’s tools (‘even the clenched fist of a human hand may be either a weapon or a tool’) ‘seem at moments indistinguishable, for they reside in a single physical object’ ( Scarry 1985 , 172). As Biss claims, pain’s enumeration is tied up with imagination, and with figurative and metaphorical languages.

Feeling my way along the lyric essay again, left to right, after this discussion of Biss’ numerical discourse, I stop. I feel disconnected from the text, explosive brain fog and unthinking holding me at a distance from the text. The text sits in front of me, under my computer screen, inviting me to read on and say interesting things. Despite this invitation, like Mel Chen, and despite the phrase’s ableist implications, I ‘feel stupid’—‘what better phrase is there, sometimes, for my force of disappointment and self-repudiation in comparison to what I expected of myself […] in this type of academic employ?’ ( Chen 2014 , 172). Despite attempting multiple immersive reading strategies (highlighting and colour-coding, excessively underlining and annotating, spatially arranging transient clouds of thought using Post-it notes), I feel that the void between me and Biss’ text is expanding, not closing. I listen to Biss in a radio interview to feel closer to her message ( Biss 2015 ). Her voice sounds weighty, measured, anchored, and her pauses in speech sound like the visible spaces on ‘The Pain Scale’. Phrases from secondary reading return to me, and I try to affix them to the context of Biss’ text. Mintz tells us that the lyric essay resists impulses to ‘superimpose narrative order on an otherwise unruly instance of pain’ and ‘might proceed as collage instead of plot’ ( Mintz 2013 , 54–55). This much, I can make sense of: Biss’ narrative moves by association and memory, not gradually unfolding, linear logic. Perhaps if the text itself is reluctant to seem orderly, it makes sense that my mind is reeling.

To recoup time lost through dissociation, I return to Robert McRuer’s early definitions of crip theory, which affirm that the ‘simultaneous articulation and disarticulation of crip identities and identifications has been part of crip theory from the start’ ( McRuer 2006 , 41). This sentence’s rhythm captures my attention: the ‘articulation and disarticulation’ establishes a pattern of saying and not saying, doing and undoing, making and unmaking (which is, of course, part of the subtitle of Scarry’s The Body in Pain ). The phrase resonates with my iterative attempts to engage with Biss’ staging of the problematic scale: I understand the overall momentum of the essay and then, on a closer look, I realise that my reading was erroneous, and I need to revise these impressions. But this back-and-forth process, reading and searching and re-reading, lends itself well to uncovering more of Biss’ questions, if not their answers.

The lyric essay resists neat conclusion, and is consistent in its ‘pursuit of answers without any expectation of finding them’ ( Moran 2018 , 1278). Biss’ arrangement of material in numbered sections ‘gesture[s] toward rationality of order’, but this orderliness remains unfulfilled when ‘the material empties out any such promise’ ( Shields 2013 , 159). This is nowhere clearer than in the essay’s final section, where:

The description of hurricane force winds on the Beaufort scale is simply, “devastation occurs.” Bringing us, of course, back to zero. (25)

Biss’ conclusion maintains the essay’s (and chronic pain’s) cyclical momentum, initiating questions which can never be answered. Brought ‘back to zero’, the essay sustains her attempt at ‘blind calculation’ (11) of pain’s intensity, continuing to articulate and disarticulate, to try and retry in a rhythm which thwarts attempts to reach coherent conclusion. This is Biss’ critique of the pain scale at its most powerful: if the pain scale poses a simple question, Biss responds that there is no singular answer, that pain experiences, memories, frames of reference, and associations make up and confound our responses. The array of vignettes and memories do not make a number: like chronic pain, they are resistant to calculation or quantification. With chronic pain, when one pain has ended, another begins. Just when an end is in sight, Biss signals a new beginning and a renewed effort, no amount of repetitions of which can conclude the attempt to put words, or numbers, to pain.

Pain’s legibility in Sonya Huber’s Pain Woman Takes your Keys

Sonya Huber’s Pain Woman Takes your Keys, and Other Essays from a Nervous System is a collection of personal essays about Hashimoto’s thyroiditis and rheumatoid arthritis ( Huber 2017 , see figure 4 ). Her essay, ‘Alternative Pain Scale’, demedicalises her pain and responds to the pain scale’s awkwardness for assessing chronic pain. What strikes me first is Huber’s volume’s sense of orderly wholeness; it feels tangibly complete, and it is unusual to be able to hold a volume of personal pain essays in my hands. The notion of textual wholeness connects with theorisations of mastery associated with autobiographical texts; to write and publish personal material implicates a distance from and control over one’s circumstances, and the neat resolution suggested by a beginning, middle and end ( Gilmore 2012 ). 6 Pain Woman, however, offers no denouement to Huber’s constant pain.

The front cover of my copy of Pain Woman , alongside the Post-it notes I find indispensable for reading and understanding texts.

‘Alternative Pain Scale’ (pp. 155–157) most overtly exemplifies Huber’s critical relationship to clinical pain assessment. Like Biss’ ‘The Pain Scale’, Huber’s essay ruminates on the confusion arising from being asked to enumerate one’s pain in the clinic. Both authors start from being disoriented by the possibilities held in the phrase ‘worst pain imaginable’. Huber’s essay opens with a description of pain scales’ difficulty:

When we go to see doctors and specialists, we are often asked to rate our pain on a 1 to 10 scale. I always get confused by this instrument, partly because I don’t know what each scale means. Is 1 “no pain,” and would 10 be “the worst pain imaginable,” such as being burned alive or torn limb from limb? Using that standard, it would seem arrogant for me to claim even an 8 if I was still able to function. So I use 1 to 7, with my 7 being “bad,” though I don’t tell my doctor this. That puts my normal pain at 3, but I’m not sure how it helps my doctor if I repeat the number 3 over and over. (155)

Huber attributes the scale’s imprecision to its anchors’ vagueness. Like Biss, Huber signals the confusion caused by ‘the worst pain imaginable’, asking whether it would entail ‘being burned alive or torn limb from limb?’—Huber conjures hypothetical pains to bring meaning to the rating experience, but rapidly discards them as unhelpful. She instead invents a personal ‘helpful replacement scale’, of which the essay is comprised, although her personal responses are, of course, too idiosyncratic to be ‘helpful’ to anyone administering or using the scale. Huber’s scale, running from 1 to 21, is a series of numbered, highly personal reactions to pain, ranging from ‘bold plans to revamp diet or try new stretches’ (point 1) to the declaration that ‘Words are hard’ when pain makes her forget her own name (point 21). Her anchors’ sense of play affords Huber the fluidity to reconcile the felt, lived, tangible, mundane elements of a life with chronic pain with the cold impersonality of the numbers used to measure it: by turns, rather than only taking root somewhere between ‘no pain’ or ‘the worst pain imaginable’, her descriptions for each number are poignant, uncertain, enraged, anxious, funny and, at times, contradictory to her earlier points. Huber’s description of reactions to pain, her descent through to 21, are synchronous with her own descent into progressively more unbearable pain.

Huber’s ‘Alternative Pain Scale’ crips VAS and Verbal Rating Scale. Her scale is a visible departure from traditional scales in length, appearance, content, and in her incorporation of idiosyncratic pain experiences. Huber forces her scale’s numbers to participate in narrating her life, furnishing numerical values with specific, emotional reactions to pain. Pain’s emotional content cannot be accommodated in Huskisson’s VAS or the FACES Scale: indeed, the FACES guidance deliberately forewarns against blurring the putative distinctions between physical and emotional pain. However, Huber is emphatic in her exploration of chronic pain’s moods and emotions: she is at turns strangely ecstatic (‘Did I invent a free and unpleasant way to get high? Everything is suddenly funny. Pain Vegas!’), overthinking and anxious (‘Do we have long-term disability? What if I can’t work anymore? […] We need to make a Plan B right now. What about eel farming? Can we put eels in the pond behind your parents’ house?’) and spiritualised by her pain (‘I’m learning something from the pain. It’s making me deep and spiritual, and I see shapes and colours’). Her range of emotional positions is also dialogical; she addresses interlocutors (her husband and mother) in her communication of pain, representing pain as relational, rather than a static number.

Life with chronic pain and illness, according to my experience, is more messy, paradoxical and disorienting than it is often possible to express; in describing it to close friends and family, we cannot help but discuss it with a wholeness and composure which casts aspersions on our claims to be in constant pain—more so for those of us whose communication styles can empty articulations of discernible emotion. There is something in Huber’s articulation of pain which calls me to re-read points on the scale. The language which dramatises her descent into pain is interesting, but most elucidating when language seems to crack from the weight of her pain. Such moments seem to transcend the most articulate explanations of pain or its intensity:

1. I have bold plans to revamp diet or try new stretches out of desperation borne by last night’s pain, and I am overjoyed and energized that I am right now not in pain. 2.I’m busy-busy-busy, because if I move fast, the pain won’t catch me! And I’m in motion now, but once I stop, I’ll be drawn to the couch with magnetic force. […] 4.Couch. All I want is my couch and Netflix. (p. 155)

Initially, Huber’s pronoun ‘I’ is what differentiates her scale from its traditionally impersonal counterpart. But Huber remains cognisant of her relationship to pain’s presence and intensity, visibly encroaching on the borders of experience. At her first point, ‘pain’ is the last word in her sentence; although she lists activities and plans with vigour, they are still tinged with an awareness of pain’s peripheral threat. At point 2, Huber declares ‘I’m busy-busy-busy, because if I move fast, the pain won’t catch me!’; the short clauses’ tempo suggests movement, energy and productivity, but also that Huber can only hold her pain one clause away from herself at a time. Point 4 begins with the abrupt declarative ‘Couch’—a one-word sentence, a piece of furniture, all she can articulate of her need for relief and comfort; point 13 is ‘I can’t read. The sentences are too hard. Remember when books?’ (156)—words and sentences become incomprehensible and uncommunicable. By the final point, she struggles to scramble together some fragments of language in a weak affirmation of identity: ‘Words are hard. My name is… something? Whatever. “Name.”’ (157).

As I read down the scale, grammatical creativity and Huber’s buoyant, playful voice give way to pain’s life-consuming tendencies. These moments, where grammar ceases to yield to convention and language cracks, resonate with my lived reality with pain. Perhaps this linguistic disintegration is what Elaine Scarry means, claiming that ‘Whatever pain achieves, it achieves in part through unsharability, and it ensures this unsharability through its resistance to language’ ( Scarry 1985 , 4). While I agree that Huber’s language is transformed by pain, I consider that this effect of pain on language does, in fact, make it shareable. Pain’s monolithic assault on language does not render Huber’s pain unshareable: rather, it is in those moments of warped grammar that I most easily recognise the debilitating onslaught of a pain flare.

Despite this, Huber wishes for pain to have a transparency and readability beyond quantification exercises. As a corollary to scales’ use of numbers, Huber imagines chronic pain to spell out messages understood in letters and words. Huber’s essay ‘The Alphabet of Pain’ is a counternarrative to the limitations and awkwardness of pain scales. This essay, and others in the collection including ‘The Lava Lamp of Pain’ and ‘Amoeba Girl’, metaphorically describe pain as legible, decipherable and visible, coterminous with her yearning for chronic pain to be recognised and understood. But Huber distinguishes between the overall experience of chronic pain and the specific, physical sensations which comprise it:

I’m not going to talk about the physical sensation. I’m after the meaning, the language of pain and its patterns. If chronic pain marks bodies, the bodies spell messages, books, libraries of possible solutions that are now as invisible as the pain itself (21).

Huber challenges existing means of recognising pain, moving from marks on a scale to figurative ‘marks’ on the body which make pain discernible. Her invocation of ‘messages, books, [and] libraries’ suggests the potential for an understanding of chronic pain achieved by reading across its ‘mark’ on individual bodies. While the description reminds readers that pain’s ‘solutions […] are now as invisible as the pain itself’, there lingers a momentary optimism in the possibility of discussing chronic pain’s complicated experiential dimensions. Huber is emphatic about the power of language, asserting that ‘Chronic pain requires words to keep it at bay’ (35), where the online communities of ‘patient advocacy blogs and message boards’, which provides a ‘path towards this [desired] heteroglossia’ and ‘pool[s] our intelligences, research, and methods for coping into a multibeing organism’ which can be channelled for physical relief and emotional reprieve. Ultimately, ‘[w]hat we need is a system that listens, first, to people who know how to write in pain’s alphabet’.

For Huber, re-imagining the pain scale in ‘Alternative Pain Scale’ simultaneously expresses disillusionment with scales’ awkwardness and re-invigorates them with her myriad voices of annoyance, ecstasy, anxiety and frustration: these voices are co-opted into sharing the work of numbers and accommodating the personal in the scale’s impersonal mechanism. Pain’s metaphorical legibility imagines an alternative to understanding another’s pain, reliant on a recognition of pain’s meaning spelt out across bodies. Unlike Biss, who dramatises numbers’ perfunctory nature to critique scales, Huber seeks solace in words, which can foster supportive and meaningful connections with others, and hold potential to spell out a more significant meaning for chronic pain.

Conclusion: encounters with texts and chronic pain

Huber’s and Biss’ cripistemologies of pain assessment offer refreshing perspectives on pain scales’ use in the medical community. Unlike the biomedical narratives I have consulted, Biss and Huber register chronic pain’s resistance to being captured by the pain scale, and, acknowledging chronic pain’s awkwardness and complexity, they illuminate the elements of imagination, speculation and memory at play in pain assessment. But these texts’ material differences fail to escape my notice.

The biomedical texts seem a little out of place in the English department where I studied prior to COVID-19: they are large, voluminous tomes, hundreds or thousands of pages long, commandeering a large space on my desk. The books, either hardbacked or held together by tightly curled spiral binding, are excessively thumbed and fingerprinted; their front covers curl inwards at the corners, suggestive of heavy use and multiple loans. Melzack and Turk (2011) announces itself with importance: gold, capitalised lettering catches the light, standing bold against a dark green, marble-effect background. By contrast, the heavily annotated printouts of literary essays or excessively Post-it noted editions of chronic pain memoirs seem quiet and inconspicuous. In Vibrant Matter , Jane Bennett observes ‘the capacity of things […] to act as quasi agents or forces with trajectories, propensities, or tendencies of their own’ ( Bennett 2010 , viii); these texts seem to pursue their own trajectories and propensities, forcing me to join in.

Pre-COVID-19, I had brief interactions which appeared to hinge on these texts; most happened when moving across campus, getting a disabled students’ allowance funded taxi, or catching a bus. While being attuned to social nuances and small talk is not my strong point, I noticed that carrying around huge biomedical textbooks drew interested questions from others, just as my purple crutch does when I am out and about. Often, my journeys are challenging aside from the inaccessibility of public transport, as I am drawn into lengthy conversation where I am frequently asked about my ‘injury’ (in response to my crutch). While I generally find small talk challenging and easily misread social cues, I find these questions about my conditions frustrating because I am always addressed as an injured young person who will heal, not as a disabled young woman who uses walking aids as her normal way of traversing the world.

Taxi drivers often draw me into conversations about these books: they ask what I am studying, and generally, they elaborate on the ‘chronic pain’ part, but disregard the ‘narratives of’. There begins an exchange where drivers relate anecdotes about relatives and friends who have been cured by various alternative therapies: I am recommended cupping therapists, dietary eliminations, exercises; I am told of devastating but erroneous diagnoses; I am asked whether there is a cure for my conditions and told aggressively to hold out hope for them. Such conversations happen far less often when I am reading Huber’s slim volume or a printout of Biss. Perhaps people see the big golden title on the marbled green cover of Handbook of Pain Assessment as a cue for the discussion of pain as a personal matter, or perhaps it is because the book is so big and unwieldy.

The literary narratives do not seem to enfold me in spontaneous commuter conversations so readily. Perhaps it is because the texts are physically small and more discreet, or perhaps reading something of specific dimensions, a printout or a small book which ‘looks’ like a novel, is less likely to elicit discussion. ‘The Pain Scale’ is stapled in the corner and unassuming among other papers on my desk. I have copies of it printed on white and green sheets, the latter to alleviate dyspraxia causing words to dance across my page. One of my copies is obsessively highlighted with an orange pen, indicative of an attempt to maintain concentration. Contrary to the densely formatted pages of the textbook, whose columns attempt to squeeze in as much information as possible, Biss’ words have space around them; they have time to unfold to relay sophisticated messages about personal feeling and experience. They are in no hurry to impart clinical knowledge. Biss’ pauses seem to speak as loudly as her words.

These exchanges suggest that there is something powerful about the impressive materiality of a chunky biomedical textbook, and perhaps less so for the quieter, smaller texts which contain stories, ideas, theories. Perhaps this is connected to value judgements about their subject areas: the overt ‘value’ of studying the STEM (science, technology, engineering and mathematics) subjects, and notions that studying fiction or the humanities is whimsical, less germane to society’s (medical) problems. But unless we start printing chronic pain narratives in large hardback books, pages divided into columns, when will it be possible to elevate personal accounts of pain to the importance of scientific theories or clinical protocols?

This article, which has held a space for both these accounts of pain assessment, has elaborated on the importance of cripistemological accounts of medical phenomena, the generativity of reading literary and biomedical accounts alongside one another, and of being attuned to the crip bodymind and the challenges of ensuing intensities while reading. Biss’ and Huber’s quiet criticism of the pain scale, enacted in the scale’s transmutation to incorporate personal voice, gets at something about the inefficacies of the pain scale so subtly and eloquently, questioning the scales’ efficiency without reinforcing the often-polarised relationship between medicine and literature. In Huber and Biss, I recognise my own experience of pain assessment, notably the experience of being dumbfounded by whatever the ‘worst imaginable pain’ might mean; indeed, both authors demonstrate the shareability of pain despite, or perhaps because of , its transmuting effect on language. Reading their accounts reminds us that there is ‘[N]o single-word anchor [which] has been identified as being the best one for the number 10’, that clinical medicine has no more an exact enumeration method than ‘the concept of Christ’. In my repeated ratings of my pain in the clinic, which often feel alienating and depersonalised, it helps to know that clinicians are considering the inefficacies and unidimensionality of the scale for chronic pain, that literary texts provide opportunities to think through thornier issues and imagine alternatives. This article expands on these means of knowing pain, demonstrating the possibilities achieved by reading different accounts of chronic pain together, and attending to those objects and circumstances on which knowledge of chronic pain rests: personal essays, medical textbooks, articles printed on coloured paper, dyspraxia, dissociation, imagination, memory, misreadings, rest breaks and conversations with fellow passengers. It nuances the understanding of pain and its assessment in the critical medical humanities, responding to pain’s representation and conceptualisation, vouching for non-normative and embodied means of doing literary analysis, and of encountering and knowing chronic pain.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

Acknowledgments.

The author thanks her supervisors and colleagues in the Medical Humanities Research Group at Leeds for their support. The author also thanks Elsevier for permissions to use the pain scale images in this article.

1. The account by Treede et al demonstrates how IASP, the International Association for the Study of Pain, uses duration in the differentiation of acute and chronic pain. The sources consulted for this article agree that chronic pain is poorly understood and resistant to medical treatment or palliation.

2. This article contributes to many challenges to Elaine Scarry’s inexpressibility theory, including discussions of pain’s generativity for writing ( Holmes and Chambers 2005 ), the development of a more complex phenomenology of pain ( McIntyre 2016 ) and an account of the nuanced language available for expressing pain ( Bustan 2016 ), among many others.

3. PoTS, or postural orthostatic tachycardia syndrome, is a condition which I struggle with. Upon standing, my blood pressure plummets and the resultant lack of blood to the brain causes instantaneous nausea and a feeling of near collapse.

4. Irlen syndrome is common in dyslexia and dyspraxia, and results in visual distortions when reading. For me, letters and words dance and shimmer about disruptively on the page or screen.

5. Statistics indicate that as many as 128 people died daily in the USA from opioid misuse or addiction in 2018, with large numbers of an increasing population of opioid users transitioning to drugs such as heroin ( National Institute on Drug Abuse 2020 ).

6. As Leigh Gilmore explores, writing on chronic pain challenges the idea of neat resolution by refusing a ‘wilful transcendence of pain’ because the pain endures. Such accounts of chronic pain also expose the coherence of the memoir’s ‘I’ as both ‘deception and error’, disrupting any expectation of mastery over the circumstances being narrated ( Gilmore 2012 , 84 and 88).

Bibliography

• Baker C. M. , and
• Chisholm-Burns M. A. ,
• Spivey C. A. ,
• Sherwin E. ,
• Wheeler J. , and
• Hohmeier K.
• Cosio D. , and
• Meshreki L. M.
• Cvetkovich A
• Garland‐Thomson R
• Singer A. J. ,
• Domingo A. , and
• Thode H. C.
• Graham S. S
• Holmes M. S. , and
• Chambers T.
• Johnson M. L. , and
• Karcioglu O. ,
• Topacoglu H. ,
• Dikme O. , and
• Sturgess J. , and
• Melzack R. , and
• McRuer R. , and
• McDowell I. , and
• National Institute on Drug Abuse
• Meldrum M. ,
• ten Have H. ,
• Seymour J. ,
• Winslow M. , and
• Pasero C. , and
• McCaffery M.
• Porter J. , and
• Malik A. , and
• Bhandari P.
• Treede R.-D. ,
• Bennett M. I. ,
• Benoliel R. ,
• Cohen M. , et al

Twitter @neko_mellor

Contributors NM is the sole author.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review Not commissioned; externally peer reviewed.

Read the full text or download the PDF:

Spine Pain Care pp 55–65 Cite as

Clinical and Research Tools for Pain Assessment

• Myrella Paschali 2 ,
• Asimina Lazaridou 2 &
• Robert R. Edwards 2  
• First Online: 08 November 2019

1660 Accesses

Pain is an internal, subjective experience that cannot be measured using physiologic markers or bioassays. The assessment of pain, therefore, relies largely on the use of self-report. Furthermore, individual differences in pain sensitivity and pain report have long remained a perplexing and challenging clinical problem. For instance, pain assessment can vary substantially across individuals based on patient demographic (e.g., culture, gender), psychosocial, and other features. Therefore, self-report measures follow a multidimensional approach aimed at characterizing multiple aspects of the pain experience such as chronicity, severity, quality, locations, affective impact, and associated factors. In special populations, limited cognitive or language skills may influence pain measures, as may the positive or negative consequences of an individual’s behaviors associate with pain.

• Pain assessment
• Self-report measures
• Screening tools
• Pain rating scales
• Behavioral observation
• Pain intensity
• Pain affect
• Quantitative sensory testing
• Disability assessment
• Pain assessment challenges

This is a preview of subscription content, log in via an institution .

Buying options

• Available as PDF
• Read on any device
• Instant download
• Own it forever
• Available as EPUB and PDF
• Compact, lightweight edition
• Dispatched in 3 to 5 business days
• Free shipping worldwide - see info
• Durable hardcover edition

Tax calculation will be finalised at checkout

Purchases are for personal use only

National Institutes of Health. Pain management. Research portfolio online reporting tools 2015. https://report.nih.gov/nihfactsheets/ViewFactSheet.aspx?csid=57 .

Dworkin RH, Bruehl S, Fillingim RB, Loeser JD, Terman GW, Turk DC. Multidimensional diagnostic criteria for chronic pain: introduction to the ACTTION-American Pain Society Pain Taxonomy (AAPT). J Pain. 2016;17(9 Suppl):T1–9. https://doi.org/10.1016/j.jpain.2016.02.010 .

Article   PubMed   Google Scholar  

Turk DC, Melzack R, editors. Handbook of pain assessment. 3rd ed. New York: Guilford Press; 2011.

Google Scholar  

Kent ML, Tighe PJ, Belfer I, Brennan TJ, Bruehl S, Terman G, et al. The ACTTION–APS–AAPM Pain Taxonomy (AAAPT) multidimensional approach to classifying acute pain conditions. J Pain. 2017;18(5):479–89. https://doi.org/10.1016/j.jpain.2017.02.421 .

Article   PubMed   PubMed Central   Google Scholar  

Melzack R, Casey KL. Sensory, motivational, and central control determinants of pain: a new conceptual model. In: Kenshalo D, editor. The skin senses. Springfield: Charles C Thomas; 1968. p. 423–43.

Jette AM. The functional status index: reliability and validity of a self-report functional disability measure. J Rheumatol. 1987;14(Suppl 15):15–21.

Wideman TH, Edwards RR, Walton DM, Martel MO, Hudon A, Seminowicz DA. The multi-modal assessment model of pain: a novel framework for further integrating the subjective pain experience within research and practice. Clin J Pain. 2018;1. https://doi.org/10.1097/AJP.0000000000000670 .

PubMed   Google Scholar  

Seymour RA. The use of pain scales in assessing the efficacy of analgesics in post-operative dental pain. Eur J Clin Pharmacol. 1982;23(5):441–4. https://doi.org/10.1007/BF00605995 .

Article   CAS   PubMed   Google Scholar  

Price DD, Bush FM, Long S, Harkins SW. A comparison of pain measurement characteristics of mechanical visual analogue and simple numerical rating scales. Pain. 1994;56(2):217–26. https://doi.org/10.1016/0304-3959(94)90097-3 .

Jensen MP, Karoly P, O’Riordan EF, Bland F, Burns RS. The subjective experience of acute pain. An assessment of the utility of 10 indices. Clin J Pain. 1989;5(2):153–9.

CAS   PubMed   Google Scholar  

Bieri D, Reeve RA, Champion GD, Addicoat L, Ziegler JB. The Faces Pain Scale for the self-assessment of the severity of pain experienced by children: development, initial validation, and preliminary investigation for ratio scale properties. Pain. 1990;41(2):139–50.

Stuppy DJ. The Faces Pain Scale: reliability and validity with mature adults. Appl Nurs Res. 1998;11(2):84–9.

Gracely RH, McGrath F, Dubner R. Ratio scales of sensory and affective verbal pain descriptors. Pain. 1978;5(1):5–18.

Price DD, Von der Gruen A, Miller J, Rafii A, Price C. A psychophysical analysis of morphine analgesia. Pain. 1985;22(3):261–9.

Duncan GH, Bushnell MC, Lavigne GJ. Comparison of verbal and visual analogue scales for measuring the intensity and unpleasantness of experimental pain. Pain. 1989;37(3):295–303.

Gaston-Johansson F. Measurement of pain: the psychometric properties of the Pain-O-Meter, a simple, inexpensive pain assessment tool that could change health care practices. J Pain Sympt Manag. 1996;12(3):172–81. https://doi.org/10.1016/0885-3924(96)00128-5 .

Article   CAS   Google Scholar  

Galer BS, Jensen MP. Development and preliminary validation of a pain measure specific to neuropathic pain: the Neuropathic Pain Scale. Neurology. 1997;48(2):332–8.

Freynhagen R, Baron R, Gockel U, Tölle TR. painDETECT: a new screening questionnaire to identify neuropathic components in patients with back pain. Curr Med Res Opin. 2006;22(10):1911–20. https://doi.org/10.1185/030079906X132488 .

Nikaido T, Sumitani M, Sekiguchi M, Konno S. The Spine painDETECT questionnaire: development and validation of a screening tool for neuropathic pain caused by spinal disorders. PLoS One. 2018;13(3):e0193987. https://doi.org/10.1371/journal.pone.0193987 .

Article   CAS   PubMed   PubMed Central   Google Scholar  

Margolis RB, Tait RC, Krause SJ. A rating system for use with patient pain drawings. Pain. 1986;24(1):57–65. https://doi.org/10.1016/0304-3959(86)90026-6 .

Toomey TC, Gover VF, Jones BN. Spatial distribution of pain: a descriptive characteristic of chronic pain. Pain. 1983;17(3):289–300. https://doi.org/10.1016/0304-3959(83)90101-X .

Melzack R. The McGill pain questionnaire: major properties and scoring methods. Pain. 1975;1(3):277–99.

Melzack R. The short-form McGill pain questionnaire. Pain. 1987;30(2):191–7. https://doi.org/10.1016/0304-3959(87)91074-8 .

Fordyce WE. Behavioral methods for chronic pain and illness. St. Louis: Mosby; 1976.

Craig KD. The facial expression of pain better than a thousand words? APS J. 1992;1(3):153–62. https://doi.org/10.1016/1058-9139(92)90001-S .

Article   Google Scholar  

Poole GD, Craig KD. Judgments of genuine, suppressed, and faked facial expressions of pain. J Pers Soc Psychol. 1992;63(5):797–805.

Prkachin KM. Assessing pain by facial expression: facial expression as nexus. Pain Res Manag. 2009;14(1):53–8.

PubMed   PubMed Central   Google Scholar  

Ekman P, Friesen WV. Measuring-facial-movement. Environ Psychol Nonverbal Behav. 1976;1(1). Retrieved from https://www.paulekman.com/wp-content/uploads/2013/07/Measuring-Facial-Movement.pdf .

Prkachin M. The consistency of facial expressions of pain: a comparison across modalities. Pain. 1992a;51:297–306.

Arendt-Nielsen L. Pain sensitisation in osteoarthritis. Clin Exp Rheumatol. 2017;35(Suppl 107(5)):68–74.

Forstenpointner J, Otto J, Baron R. Individualized neuropathic pain therapy based on phenotyping: are we there yet? Pain. 2018;159(3):569–75. https://doi.org/10.1097/j.pain.0000000000001088 .

Mao J. Opioid-induced hyperalgesia. New York: Informa Healthcare USA; 2010.

Compton P, Charuvastra VC, Ling W. Pain intolerance in opioid-maintained former opiate addicts: effect of long-acting maintenance agent. Drug Alcohol Depend. 2001;63(2):139–46.

Doverty M, White JM, Somogyi AA, Bochner F, Ali R, Ling W. Hyperalgesic responses in methadone maintenance patients. Pain. 2001;90(1–2):91–6.

Coghill RC, Eisenach J. Individual differences in pain sensitivity: implications for treatment decisions. Anesthesiology. 2003;98(6):1312–4.

Barad MJ, Ueno T, Younger J, Chatterjee N, Mackey S. Complex regional pain syndrome is associated with structural abnormalities in pain-related regions of the human brain. J Pain. 2014;15(2):197–203. https://doi.org/10.1016/j.jpain.2013.10.011 .

Borsook D, Becerra L, Fava M. Use of functional imaging across clinical phases in CNS drug development. Transl Psychiatry. 2013;3(7):e282. https://doi.org/10.1038/tp.2013.43 .

Smith SM, Dworkin RH, Turk DC, Baron R, Polydefkis M, Witter J, et al. The potential role of sensory testing, skin biopsy, and functional brain imaging as biomarkers in chronic pain clinical trials: IMMPACT considerations. J Pain. 2017;18(7):757–77. https://doi.org/10.1016/j.jpain.2017.02.429 .

Chapin H, Bagarinao E, Mackey S. Real-time fMRI applied to pain management. Neurosci Lett. 2012;520(2):174–81. https://doi.org/10.1016/j.neulet.2012.02.076 .

Davis KD. Legal and ethical issues of using brain imaging to diagnose pain. Pain Rep. 2016;1(4). https://doi.org/10.1097/PR9.0000000000000577 .

McGrath PJ, Walco GA, Turk DC, Dworkin RH, Brown MT, Zeltzer L. Core outcome domains and measures for pediatric acute and chronic/recurrent pain clinical trials: PedIMMPACT recommendations. J Pain. 2008;9(9):771–83. https://doi.org/10.1016/j.jpain.2008.04.007 .

von Baeyer CL, Spagrud LJ. Systematic review of observational (behavioral) measures of pain for children and adolescents aged 3 to 18 years. Pain. 2007;127(1–2):140–50. https://doi.org/10.1016/j.pain.2006.08.014 .

Lawrence J, Alcock D, McGrath P, Kay J, MacMurray SB, Dulberg C. The development of a tool to assess neonatal pain. Neonatal Netw. 1993;12(6):59–66.

Gibson SJ, Lussier D. Prevalence and relevance of pain in older persons. Pain Med. 2012;13(Suppl 2):S23–6. https://doi.org/10.1111/j.1526-4637.2012.01349.x .

Bruckenthal P. Clinics in geriatric medicine, 2008. In: Assessment of pain in the elderly adult-ClinicalKey. Retrieved November 24, 2018, from https://www-clinicalkey-com.ezp-prod1.hul.harvard.edu/#!/content/playContent/1-s2.0-S0749069007001061?returnurl=null&referrer=null .

Cleeland CS, Ryan KM. Pain assessment: global use of the brief pain inventory. Ann Acad Med Singap. 1994;23(2):129–38.

Tait RC, Chibnall JT, Krause S. The pain disability index: psychometric properties. Pain. 1990;40(2):171–82. https://doi.org/10.1016/0304-3959(90)90068-O .

Gloth FM, Scheve AA, Stober CV, Chow S, Prosser J. The Functional Pain Scale: reliability, validity, and responsiveness in an elderly population. J Am Med Dir Assoc. 2001;2(3):110–4.

Kerns RD, Turk DC, Rudy TE. The West Haven-Yale Multidimensional Pain Inventory (WHYMPI). Pain. 1985;23(4):345–56. https://doi.org/10.1016/0304-3959(85)90004-1 .

Ferrell BA, Ferrell BR, Rivera L. Pain in cognitively impaired nursing home patients. J Pain Symptom Manag. 1995;10(8):591–8.

CAS   Google Scholar  

Hadjistavropoulos T, Herr K, Turk DC, Fine PG, Dworkin R, Williams J, et al. An interdisciplinary expert consensus statement on assessment of pain in older persons. Clin J Pain. 2007;23(1 Suppl):S1–43. https://doi.org/10.1097/AJP.0b013e31802be869 .

LaChapelle DL, Hadjistavropoulos T, Craig KD. Pain measurement in persons with intellectual disabilities. Clin J Pain. 1999;15(1):13–23.

Malara A, De Biase GA, Bettarini F, Ceravolo F, Di Cello S, Rispoli V, et al. Pain assessment in elderly with behavioral and psychological symptoms of dementia. J Alzheimers Dis. 2016;50(4):1217–25. https://doi.org/10.3233/JAD-150808 .

Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) scale. J Am Med Dir Assoc. 2003;4(1):9–15. https://doi.org/10.1097/01.JAM.0000043422.31640.F7 .

Kunz M, Scharmann S, Hemmeter U, Schepelmann K, Lautenbacher S. The facial expression of pain in patients with dementia. Pain. 2007;133(1–3):221–8. https://doi.org/10.1016/j.pain.2007.09.007 .

Chan S, Hadjistavropoulos T, Williams J, Lints-Martindale A. Evidence-based development and initial validation of the pain assessment checklist for seniors with limited ability to communicate-II (PACSLAC-II). Clin J Pain. 2014;30(9):816–24. https://doi.org/10.1097/AJP.0000000000000039 .

Stubbs B, Thompson T, Acaster S, Vancampfort D, Gaughran F, Correll CU. Decreased pain sensitivity among people with schizophrenia: a meta-analysis of experimental pain induction studies. Pain. 2015;156(11):2121–31. https://doi.org/10.1097/j.pain.0000000000000304 .

Potvin S, Marchand S. Hypoalgesia in schizophrenia is independent of antipsychotic drugs: a systematic quantitative review of experimental studies. Pain. 2008;138(1):70–8. https://doi.org/10.1016/j.pain.2007.11.007 .

Singh MK, Giles LL, Nasrallah HA. Pain insensitivity in schizophrenia: trait or state marker? J Psychiatr Pract. 2006;12(2):90–102.

Pasero C, McCaffery M. Pain assessment and pharmacologic management. 1st ed. Philadelphia: Elsevier; 2011; ISBN 9780323056960.

Watson GD, Chandarana PC, Merskey H. Relationships between pain and schizophrenia. Br J Psychiatry. 1981;138:33–6.

Norman SB, Stein MB, Dimsdale JE, Hoyt DB. Pain in the aftermath of trauma is a risk factor for post-traumatic stress disorder. Psychol Med. 2008;38(4):533–42. https://doi.org/10.1017/S0033291707001389 .

Asmundson GJ, Coons MJ, Taylor S, Katz J. PTSD and the experience of pain: research and clinical implications of shared vulnerability and mutual maintenance models. Can J Psychiatr. 2002;47(10):930–7. https://doi.org/10.1177/070674370204701004 .

Fillingim RB, King CD, Ribeiro-Dasilva MC, Rahim-Williams B, Riley JL. Sex, gender, and pain: a review of recent clinical and experimental findings. J Pain. 2009;10(5):447–85. https://doi.org/10.1016/j.jpain.2008.12.001 .

Pieretti S, Di Giannuario A, Di Giovannandrea R, Marzoli F, Piccaro G, Minosi P, et al. Gender differences in pain and its relief. Annali Dell’Istituto Superiore Di Sanita. 2016;52(2):184–9. https://doi.org/10.4415/ANN_16_02_09 .

Fillingim RB, Maixner W. Gender differences in the responses to noxious stimuli. Pain Forum. 1995;4(4):209–21. https://doi.org/10.1016/S1082-3174(11)80022-X .

Riley JL, Robinson ME, Wise EA, Myers CD, Fillingim RB. Sex differences in the perception of noxious experimental stimuli: a meta-analysis. Pain. 1998;74(2–3):181–7.

LeResche L, Mancl L, Sherman JJ, Gandara B, Dworkin SF. Changes in temporomandibular pain and other symptoms across the menstrual cycle. Pain. 2003;106(3):253–61.

Brynhildsen JO, Björs E, Skarsgård C, Hammar ML. Is hormone replacement therapy a risk factor for low back pain among postmenopausal women? Spine. 1998;23(7):809–13.

Zubieta J-K, Smith YR, Bueller JA, Xu Y, Kilbourn MR, Stohler CS, et al. μ-opioid receptor-mediated antinociceptive responses differ in men and women. J Neurosci. 2002;22(12):5100–7.

CAS   PubMed   PubMed Central   Google Scholar  

Peacock S, Patel S. Cultural influences on pain. Rev Pain. 2008;1(2):6–9. https://doi.org/10.1177/204946370800100203 .

Shavers VL, Bakos A, Sheppard VB. Race, ethnicity, and pain among the U.S. adult population. J Health Care Poor Underserved. 2010;21(1):177–220. https://doi.org/10.1353/hpu.0.0255 .

Giger JN, Davidhizar RE. Transcultural nursing: assessment and intervention. 5th ed. London: Mosby; 2008.

Redelmeier DA. Patients’ memories of painful medical treatments: real-time and retrospective evaluations of two minimally invasive procedures. Pain. 1996;66:3–8.

Gedney JJ, Logan H. Pain related recall predicts future pain report. Pain. 2006;121(1):69–76. https://doi.org/10.1016/j.pain.2005.12.005 .

Eich E, Reeves JL, Jaeger B, Graff-Radford SB. Memory for pain: relation between past and present pain intensity. Pain. 1985;23(4):375–80.

de la Vega R, Roset R, Castarlenas E, Sánchez-Rodríguez E, Solé E, Miró J. Development and testing of painometer: a smartphone app to assess pain intensity. J Pain. 2014;15(10):1001–7. https://doi.org/10.1016/j.jpain.2014.04.009 .

Liew CV, Standridge K, Leon G, Cronan TA. A longitudinal analysis of pain experience and recall in fibromyalgia. Int J Rheum Dis. 2018. https://doi.org/10.1111/1756-185X.13415 .

World Health Organization. International classification of functioning, disability, and health: ICF. Geneva: World Health Organization; 2001.

Lin CW, McAuley JH, Macedo L, Barnett DC, Smeets RJ, Verbunt JA. Relationship between physical activity and disability in low back pain: a systematic review and meta-analysis. Pain. 2011;152(3):607–13. https://doi.org/10.1016/j.pain.2010.11.034 .

Verbunt JA, Huijnen IP, Köke A. Assessment of physical activity in daily life in patients with musculoskeletal pain. Eur J Pain. 2009;13(3):231–42. https://doi.org/10.1016/j.ejpain.2008.04.006 .

Stevens ML, Lin CC, Maher CG. The Roland Morris disability questionnaire. J Physiother. 2016;62(2):116. https://doi.org/10.1016/j.jphys.2015.10.003 .

Smeets R, Köke A, Lin C-W, Ferreira M, Demoulin C. Measures of function in low back pain/disorders: Low Back Pain Rating Scale (LBPRS), Oswestry Disability Index (ODI), Progressive Isoinertial Lifting Evaluation (PILE), Quebec Back Pain Disability Scale (QBPDS), and Roland-Morris Disability Questionnaire (RDQ). Arthritis Care Res. 2011;63(S11):S158–73. https://doi.org/10.1002/acr.20542 .

Kopec JA, Esdaik JM, Abrahamowicz M, Abe L, Wood-Dauphinee S, Lumping DL, et al. The Quebec back pain disability scale: conceptualization and development. J Clin Epidemiol. 1996;49(2):151–61.

Sadaf D, Ahmad MZ. Factors associated with postoperative pain in endodontic therapy. Int J Biomed Sci. 2014;10(4):5.

Download references

Author information

Authors and affiliations.

Department of Anesthesiology, Brigham and Women’s Hospital, Chestnut Hill, MA, USA

Myrella Paschali, Asimina Lazaridou & Robert R. Edwards

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Robert R. Edwards .

Editor information

Editors and affiliations.

Richard J. Kitz Professor of Anesthesia Research Harvard Medical School, Harvard University, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA

Jianren Mao

Rights and permissions

Reprints and permissions

Copyright information

© 2020 Springer Nature Switzerland AG

About this chapter

Cite this chapter.

Paschali, M., Lazaridou, A., Edwards, R.R. (2020). Clinical and Research Tools for Pain Assessment. In: Mao, J. (eds) Spine Pain Care. Springer, Cham. https://doi.org/10.1007/978-3-030-27447-4_6

Download citation

DOI : https://doi.org/10.1007/978-3-030-27447-4_6

Published : 08 November 2019

Publisher Name : Springer, Cham

Print ISBN : 978-3-030-27446-7

Online ISBN : 978-3-030-27447-4

eBook Packages : Medicine Medicine (R0)

Share this chapter

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Publish with us

Policies and ethics

• Find a journal
• Track your research

Cripping the pain scale: literary and biomedical narratives of pain assessment

Affiliation.

• 1 School of English, University of Leeds, Leeds, UK [email protected].
• PMID: 37130743
• DOI: 10.1136/medhum-2022-012484

This article analyses the literary representation of pain scales and assessment in two chronic pain narratives: 'The Pain Scale', a lyric essay by Eula Biss, and essays from Sonya Huber's collection Pain Woman Takes Your Keys, and Other Essays from a Nervous System Establishing first a brief history of methods attempting to quantify pain before my close reading, I read both Biss' and Huber's accounts as performative explorations of the limitations of using linear pain scales for pain which is recursive and enduring. Considering both texts as cripistemologies of chronic pain, my literary analysis attends to their criticism of the pain scale, including its implicit reliance on imagination and memory, and how its unidimensionality and synchronic focus prove inadequate for lasting pain. For Biss, this surfaces as a quiet critique of numbers and a disturbance of their fixity, while Huber's criticism employs the motif of pain's legibility across multiple bodies to spell out alternative meanings of chronic pain.Crucially, this article proposes a crip and embodied approach for reading and responding to accounts of chronic pain's measurement, including Biss' and Huber's literary accounts, and the biomedical account of pains scales which this article reads alongside them. The article's analysis draws on my personal experience of chronic pain, neurodivergence and disability to demonstrate the generativity of an embodied approach to literary analysis. Rather than bowing to the impulse to impose false coherence on my reading of Biss and Huber, my article foregrounds the impact of the re-reading, misreading, cognitive dissonance and breaks necessitated by chronic pain and processing delays on this analysis. In bringing an ostensibly crip methodology to bear on readings of chronic pain, I hope to invigorate discussions on reading, writing and knowing chronic pain in the critical medical humanities.

Keywords: Medical humanities; Pain management; literary studies; literature and medicine; patient narratives.

© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.

• Chronic Pain*
• Imagination
• Pain Measurement

This website is intended for healthcare professionals

• { $refs.search.focus(); })" aria-controls="searchpanel" :aria-expanded="open" class="hidden lg:inline-flex justify-end text-gray-800 hover:text-primary py-2 px-4 lg:px-0 items-center text-base font-medium"> Search

Search menu

Abbey J, Piller N, De Bellis A The Abbey pain scale: a 1-minute numerical indicator for people with end-stage dementia. Int J Palliat Nurs. 2004; 10:(1)6-13 https://doi.org/10.12968/ijpn.2004.10.1.12013

Boore J, Cook N, Shepherd A. Essentials of anatomy and physiology for nursing practice.Los Angeles: Sage; 2016

Colvin LA, Carty S. Neuropathic pain. In: Colvin LA, Fallon M (eds). Chichester: BMJ Books/Wiley; 2012

Cullen M, MacPherson F. Complementary and alternative strategies. In: Colvin LA, Fallon M (eds). Chichester: BMJ Books/Wiley; 2012

Cunningham S. Pain assessment and management. In: Moore T, Cunningham S (eds). Abingdon: Routledge; 2017

Flasar CE, Perry AG. Pain assessment and basic comfort measures, 8th edn. In: Perry AG, Potter PA, Ostendorf WR (eds). London: Mosby/Elsevier; 2014

Johnson MI. The role of transcutaneous electrical nerve stimulation TENS on pain management. In: Colvin LA, Fallon M (eds). Chichester: BMJ Books/Wiley; 2012

Kettyle A. Pain management, 1st edn. In: Delves-Yates C (ed). London: Sage; 2015

Laws P, Rudall N. Assessment and monitoring of analgesia, sedation, delirium and neuromuscular blockade levels and care. In: Mallet J, Albarran JW, Richardson A (eds). Chichester: Wiley; 2013

Mears J. Pain management. In: Dutton H, Finch J (eds). Chichester: Wiley; 2018

Melzack R. The McGill pain questionnaire: major properties and scoring methods. Pain. 1975; 1:(3)277-299

Smith MT, Muralidharan A. Pain pharmacology and the pharmacological management of pain, 2nd edn. In: Van Griensven H, Strong J, Unruh AM (eds). London: Elsevier; 2014

World Health Organization. WHO's cancer pain ladder for adults. 2019. http://tinyurl.com/y4u2ghok (accessed 28 March 2019)

Adult pain assessment and management

Claire Ford

Lecturer, Adult Nursing, Northumbria University, Newcastle upon Tyne, explain how to reduce the risk of contamination

View articles · Email Claire

Claire Ford, Lecturer, Adult Nursing, Northumbria University, Newcastle upon Tyne ([email protected]) outlines the skills and tools health professionals use to help patients manage pain

For health professionals, one of the most common patient problems they will encounter is pain. Although this is universally experienced, effective assessment and management is sometimes difficult to achieve, as pain is also extremely complex. Therefore, when a patient states they are in pain it is every health professional's duty to listen to what they say, believe that pain is what they say it is, observe for supporting information using appropriate and varied assessment approaches, and act as soon as possible using suitable management strategies.

The holistic assessment and management of pain is important, as pain involves the mind as well as the body, and is activated by a variety of stimuli, including biological, physical, and psychological ( Boore et al, 2016 ). For some patients, the pain they experience can be short-lived and easy to treat, but for others, it can cause significant issues in relation to their overall health and wellbeing ( Flasar and Perry, 2014 ).

Mismanaged pain can affect an individual's mobility, sleep pattern, nutritional and hydration status and can increase their risk of developing depression or becoming socially withdrawn ( Mears, 2018 ). As nurses are the frontline force in healthcare settings, they play a vital role in the treatment of individuals in pain. This article examines and explores some of the holistic nursing assessment and management strategies that can be used by health professionals.

Classifications of pain

Before diving into the assessment process, it is necessary to have a general understanding of the various types of pain that can be experienced, as well as how these are manifested. This understanding will ultimately help to inform management decisions—it is the first step in the assessment process ( Boore et al, 2016 ).

There are several classifications of pain (see Table 1 ); some overlap and patients may present with one or more. Pain can be:

• Acute: pain that is of short duration (less than 3 months) and is reversible
• Chronic: pain that is persistent and has been experienced for more than 3 months
• Nociceptive: pain resulting from stimulation of pain receptors by heat, cold, stretching, vibration or chemicals
• Neuropathic: pain related to sensory abnormalities that can result from damage to the nerves (nerve infection) or neurological dysfunction (a disease in the somatosensory nervous system)
• Inflammation: stimulation of nociceptive processes by chemicals released as part of the inflammatory process
• Somatic: nociceptive processes activated in skin, bones, joints, connective tissues and muscles
• Visceral: nociceptive processes activated in organs (eg stomach, kidneys, gallbladder)
• Referred: pain that is felt a distance from the site of origin. ( Colvin and Carty, 2012 ; Laws and Rudall, 2013 ; Kettyle, 2015 ; Boore et al, 2016 ; Cunningham, 2017 ; Mears, 2018 ).

Individuals react to pain in varying ways; for some, pain is seen as something that should be endured, while for others it can be a debilitating problem, which is impeding their ability to function. Therefore, in order to develop an effective and individually tailored holistic management plan, it is important to understand how the pain is uniquely affecting the individual, from a biopsychosocial perspective ( Flasar and Perry, 2014 ).

To do this, health professionals use a range of tools, such as the skills of observation (the art of noticing), questioning techniques, active listening, measurement and interpretation. No one skill is superior; rather, it is the culmination of information gathered via the various methods that enables a health professional to determine if a patient is in pain, and how this pain is affecting them physically, psychologically, socially, and culturally ( Cunningham, 2017 ) ( Table 2 ).

One of the first skills that can be used is to visually observe the patient, and examine body language, facial expressions, and behaviours, as these provide information about how a person is feeling. For example, an individual in pain may be quiet and withdrawn or very vocal, angry, and irritable. They may display facial grimacing and teeth clenching or exhibit negative body language, guarding and an altered gait.

However, there may be times when an individual may not be able to show behavioural signs of pain, such as when a patient is unconscious. Therefore, physiological response to noxious stimuli can be observed through the measurement of vital signs, such as hypertension, tachycardia, and tachypnoea. Although these observations are routinely used within perioperative and critical care areas, these signs can be present in the absence of pain; consequently, these must be used in conjunction with other assessment strategies ( Laws and Rudall, 2013 ).

Assessment tools

Although vital observations and behavioural manifestations may indicate that a patient is in pain, questioning, measurement and interpretation skills will assist with determining the intensity, severity, and effect of the pain on the patient's wellbeing and quality of life. This process can be aided with the use of specifically designed tools, which act as prompts for health professionals and facilitate the assessment of one or more dimensions.

Unidimensional tools

A visual analogue scale (VAS), numerical rating scale (NRS), or verbal rating scale (VRS) can be quick, easy to use, regularly repeated and do not require complex language. These are limited in terms of the information gained, as examining one specific aspect is not sufficient for adequate and holistic pain management ( Mears, 2018 ). However, for individuals who are unable to communicate or where language barriers exist, unidimensional tools, such as the Wong-Baker FACES tool can be very useful ( Kettyle, 2015 ). The Wong-Baker FACES tool (https://wongbakerfaces.org/), which was originally created for children, has been successfully integrated into the care of older people (with or without cognitive impairment) and is beneficial in facilitating an individual's ability to communicate if they are experiencing pain.

Multidimensional tools

These ask for greater information and measure the quality of pain via affective, evaluative and sensory means. The McGill Pain Questionnaire (MPQ) is one example ( Melzack, 1975 ). This long-established tool is often used to assess individuals who are experiencing chronic pain. However, due to its higher levels of complexity health professionals can sometimes find this tool more difficult to use, especially if unfamiliar with it. The Abbey pain scale ( Abbey et al, 2004 ) is another multidimensional tool that has proven to be beneficial for assessing pain in older adults who are unable to articulate their needs.

OPQRST and SOCRATES are just two examples of mnemonic aids, which can be useful and require no equipment as they use mental assessment processes only. OPQRST stands for onset, provokes, quality, radiates, severity and time. SOCRATES stands for site, onset, character, radiates, associations, timing, exacerbating factors and severity.

However, regardless of which tool or mnemonic is used, because pain presentations are often unique pain assessment will not be successful if the health professional fails to ascertain and interpret the signs and symptoms, uses the tools inappropriately, and does not apply a person-centred approach to the overall assessment process, ie uses the wrong tool for the wrong patient.

Management strategies

The primary goal for all patients is to pre-empt and prevent pain from occurring in the first instance; however, if pain cannot be avoided, optimal analgesic management is vital.

The word analgesia, ‘to be without feeling of pain’, is derived from the Greek language, and in terms of pain management can relate to medication and alternative interventions ( Laws and Rudall, 2013 ). Hence, pain management plans should incorporate a multi-modal approach in order to successfully and holistically treat patients' pain ( Flasar and Perry, 2014 ). Boore et al (2016) argued that this is an effective way to manage pain, but stressed that the decisions about which management strategies to use, also need to take into consideration the context of the clinical situation, the patient's level of acuity, the environment and physical space, and the availability of resources.

Pharmacological

One very effective strategy that health professionals have within their management arsenal is the use of pharmacological treatments. The choice of treatment depends on whether the pain is nociceptive, neuropathic, inflammatory or of mixed origin. There are three main categories: opioids, non-opioids/non-steroidal anti-inflammatories, and adjuvants/co-analgesics ( Table 3 ). The most efficient pharmacological regime, for moderate to severe pain (ie cancer-related pain) often incorporates a combined approach, by administrating a specific drug in conjunction with adjuvants or co-analgesics ( Figure 1 ).

Non-pharmacological

Pharmacological treatments are not the only strategy at health professionals' disposal, and true holistic management cannot be achieved without the incorporation of other non-pharmacological therapies. Some of these interventions are long-standing, are ingrained in some traditional medical practices and, when used correctly, can enhance patients' feelings of empowerment and involvement ( Flasar and Perry, 2014 ). However, due to limited resources, funding, space, time, knowledge of use, and personal beliefs, some therapies are not fully used or embraced ( Cullen and MacPherson, 2012 ).

These can be placed into three main groups ( Table 4 ), and the choice of which to use will depend on patients' preferences and existing coping mechanisms. The following strategies have been highlighted as they align with the fundamental core values of care and compassion, and require very little in terms of resources or time.

• Distraction: this can take various forms, such as talking to the patient about their specific hobbies. This basic skill often requires no equipment, can be done anywhere and is a useful way of taking the patient's mind off their pain
• Imagery/meditation: this management technique takes distraction therapy one step further by using a more structured approach
• Therapeutic touch and massage: for centuries, the therapeutic placing of hands has proven to be a useful skill, and has beneficial physiological (stimulation of A-beta fibres, which restrict pain pathways) and psychological properties ( Kettyle, 2015 ).
• Environment: sound, lighting and the temperature of the patient's immediate environment have been shown to heighten or reduce perceptions of pain
• Body positioning and comfort: this can be used to help patients cope with the pain levels they are experiencing and may reduce the pain associated with nociceptive and inflammatory pain signals
• Thermoregulation: for some types of pain, it has been shown that the use of heat or cold packs can help reduce pain experiences. However, care needs to be taken if these treatments are to be used on postoperative sites and areas with skin-related contraindications
• Electrostimulation: this technique is non-invasive and uses pulsed electrical currents to stimulate A-beta fibres, which inhibit the transmission of nociceptive signals in the pain pathway ( Johnson, 2012 ).

Successful pain assessment and management can only be achieved if health professionals adopt a holistic and multimodal approach, incorporating the use of person-centred assessment processes, compassionate communication and a variety of management strategies, chosen in partnership with the patient.

LEARNING OUTCOMES

• Have a basic understanding of some of the classifications of pain
• Improve awareness of the skills required to assess and manage an individual's pain
• Explore some of the tools used to assist with the assessment of pain
• Understand some of the strategies used to manage pain
• Examine some of the barriers to effective pain assessment and management

Competence or Experience The Missing Voice in Pediatric Decision-Making

Article sidebar.

Main Article Content

Photo ID 129550171© Katarzyna Bialasiewicz|Dreamstime.com

INTRODUCTION

One night in 2016, I fell sound asleep, then awoke to painkiller-induced, nightmarish hallucinations in the ICU. Despite being unable to identify myself or surroundings, I can clearly remember the discordant beeping of hospital monitors, acrid smell of saline wash, and taste of sickly sweet orange amoxicillin syrup. I was unaware that, the morning after I’d fallen asleep, I’d skied off an unmarked 30-foot cliff, breaking my legs, jaw, eye socket and nose, rupturing my right ear canal, and shattering nearly all of my teeth. Over the years that followed, I was fortunate enough to receive care from skilled, compassionate physicians. This not only allowed me to return to ski racing, but to dream of becoming a surgeon. Having grown older and thus more aware throughout my years as a pediatric patient, I’ve developed a nuanced understanding of what treatment made me feel heard.

In fact, I found the most radically varying aspect of my care to be the degree to which I was addressed as a conscious, capable individual versus an extension of my parents. This is unsurprising as the proper amount of authority lended to pediatric patients persists as highly disputed in bioethics. Over the course of this paper, several perspectives will be considered in order to evaluate the current position of the pediatric patient in medical decision-making. First, the ambiguity of maturity and reactions to pediatric autonomy will be considered through the Mature Minor Doctrine, especially important in the refusal of life-saving therapies. Next, the need for improved pain management, rooted in the misalignment of experienced and perceived pain in pediatric patients. Finally, this paper will prove, through the lenses of communitarianism and mosaic decision-making, the need for a more nuanced approach to pediatric care that structurally accounts for the patient’s voice without neglecting their place within a greater network. Therefore, there exists a great need for a more direct, balanced integration of pediatric patients’ as well as revisiting prevailing notions of where pediatric patients stand in relation to reason and experience.

To begin, Fleischman’s Pediatric Ethics opens with an exploration of what makes pediatric bioethics distinct. [1] Fleischman quickly runs into the most problematic of principles in the treatment of pediatric patients– autonomy. The ethical ambiguity of the degree of autonomy to offer pediatric patients and at what point in their lives is a central point of conflict. Many in favor of expanded authority point to the neurobiological similarity between young adults and late teenagers. [2] Furthermore, while parents are treated as natural decision-makers for their children, there are several cases of minors facing pressure to undergo medical treatment against their wishes. [3] , [4]  In response to these concerns, the Mature Minor Doctrine was created, a common law exception to the parental consent requirement. The doctrine allows a minor “to refuse or consent to medical treatment if [they possess] sufficient maturity to understand and appreciate the benefits and risks of the proposed medical treatment.” [5] The doctrine has spurred extensive and impassioned bioethical discourse, especially in relation to the refusal of life-saving therapies.

In “Health Care Decisionmaking by Children'', Ross draws a clear distinction between the notion of competence, often cited in psychological justifications of the Mature Minor Doctrine, and sound judgment. [6]  Her points against child liberationists can be simplified as follows: (a) children need time to develop virtues that preserve their life-time autonomy versus their present-day autonomy, (b) pediatric patients possess “limited world experience and so [their] decisions are not part of a well-conceived life plan,” [7] and (c) it serves parents and children alike for parents to make decisions in line with their view of a good life. I find all three points convincing, but each of them to be uniquely rooted in this same, critical lack of experience possessed by pediatric patients. I can attest to this. There were times where I suffered so desperately that I longed for relief by any means. I even told my mother that I was content only hearing out of one ear, willing to do anything to prevent another surgery. Now, I am fearful to imagine a world where, at my lowest, I had full autonomy.

Hence, the broad aversion to expanded pediatric autonomy is largely rooted in potential misuse, especially in the possibility of a unilateral, misinformed decision in favor of death via refusal of life-sustaining therapy. [8] , [9] Yet, one might argue, the desire for death has concrete rationale beyond lack of life experience— pain and suffering. As Foley describes, “The public's fear of pain and the media's portrayal that physician-assisted suicide and euthanasia are the only reliable options for pain relief… demand that health care delivery systems commit their efforts to improve pain relief at an institutional level.” [10]  Indeed, the issue of insufficient pain management is all too common in pediatrics. One study comparing postoperative pain assessments surveyed 307 patients, 207 of whom were verbal. Across the board, nurses’ pain estimations produced significantly lower pain scores than parents and children, and were consistently closer to estimated pain scores of independent observers. [11] In another study, a total of 356 nurses across 22 Japanese PICUs were surveyed, and despite possessing a median of 4 years of experience, a mere 32.6% expressed confidence in their ability to accurately assess pain. [12]   It is alarming and telling that even in verbal pediatric patients, pain is significantly underestimated by medical personnel, reflecting a real gap in pediatric patient-professional communication. I can, again, personally attest to this. In the children’s ward, I was offered only Tylenol for severe nerve pain in my legs that kept me awake most nights.

Relatedly, the spirited debate in response to the Mature Minor Doctrine is somewhat disproportionate. Despite the suggestion of various commentators that the law broadly recognizes the doctrine or that states are trending in its direction, only eight states have adopted a mature minor exception, and even these states condition this authority greatly. [13] With this in mind, a crucial issue is illuminated– an aversion to the pediatric patient voice altogether. As Flesichman writes, “Children should be informed about the nature of their condition, the proposed treatment plan, and the expected outcome… appropriate to their developmental levels.” [14] Hence, it is vital to curtail pediatric autonomy in complex and life-threatening choices, but it is worth seriously considering that the current landscape might excessively minimize or avoid pediatric patients’ expression, merely serving to inform them rather than account for their voice.

The experience that pediatric patients do possess, in the form of knowing their body, past medical experiences, and thus present pain-related needs, is systemically underrepresented. This is a pressing issue. Before considering expansion of the pediatric voice, though, it is first important to consider the manner in which the patient’s capacity is further complicated by their role within a larger community. It is worthwhile explicitly mentioning communitarianism, a prevailing school of thought in modern bioethics, defined by Callahan as “a way of… assum[ing] that human beings are social animals… and whose lives are lived out within deeply penetrating social, political, and cultural institutions and practices.” [15] Pediatric patients present a uniquely communitarian case as the perspectives of parents and the needs of patients’ families are vital considerations in offering care. The pediatric patient’s role in a larger family unit and community should be kept in focus so long as the well-being of the patient isn’t compromised, such as in potentially life-threatening religious preferences, as the obligation of the physician is, first and foremost, to the patient.

Nonetheless, the status quo demands a more thoughtful and structural accounting of the pediatric voice to ensure that they feel heard and empowered in complex decision-making and regular care alike. Hence, it is necessary to develop and evaluate clinical models and frameworks that directly account for the pediatric voice, that integrate pediatric patients’ input as continuous, regular, and required elements of treatment. For instance, there may be promise in a model similar to that of mosaic decision-making, a means of restoring the capacity of reemergent patients following brain injury. Rather than enabling complete surrogate authority, the model would enable a pediatric patient’s emergent voice to be accommodated but to not “speak beyond its range and capabilities” via group deliberation between surrogate and patient, a medical professional, and a patient advocate. [16] Opting for such a model would enable the active involvement of pediatric input without excessively empowering the patient in a manner that neglects their communitarian role and lack of experience.

In the heated response to the largely unenforced mature minor doctrine, one finds the invaluable and lacking factor of experience in pediatric patients, especially in decisions to withdraw or refuse life-sustaining medical treatments. In this same response, however, one finds a sharp aversion to the pediatric voice, reflected in pervasive under-medication. Deficits in pain management must be addressed to more effectively treat discomfort, an effort bolstered by a more structural accounting of the pediatric voice and thus pain-related needs. Finally, frameworks that regularly involve the pediatric patient perspective while valuing their communitarian importance and lacking experience, such as the mosaic model, hold real promise moving forward.

[1] Fleischman, Alan. Pediatric Ethics: Protecting the Interests of Children. (Oxford: Oxford University Press, September, 2016), p. 1-16.

[2] Coleman, Doriane & Rosoff, Philip. “The Legal Authority of Mature Minors to Consent to General Medical Treatment.” (Itasca: American Journal of Pediatrics, March  2013), p. 1.

[3] Hawkins, Susan. “Protecting the Rights and Interests of Competent Minors in Litigated Medical Treatment Disputes.” (New York: Fordham Law Review, March 1996), p. 1.

[4] Derish, Melinda & Heuvel, Kathleen. “Mature Minors Should Have the Right to Refuse Life-Sustaining Medical Treatment.” (Boston: The

Journal of Law, Medicine & Ethics, January 2021), p. 1-14.

[5] Derish, Melinda & Heuvel, Kathleen. “Mature Minors Should Have the Right to Refuse Life-Sustaining Medical Treatment.” p. 7.

[6] Ross, Lainie. “Health Care Decisionmaking by Children. Is It in Their Best Interest?” (Garrison: The Hastings Center Report, November-December 1997), p. 1-5.

[7] Ross. “Health Care Decisionmaking by Children''. p. 5.

[8] Penkower, Jessica. “The Potential Right of Chronically Ill Adolescents to Refuse Life-Saving Medical Treatment - Fatal Misuse of the Mature Minor Doctrine.” (Chicago: DePaul Law Review, 1996), p. 1-8.

[9] Burk, Josh. “Mature Minors, Medical Choice, and the Constitutional Right to Martyrdom.” (Charlottesville: Virginia Law Review, September 2016), p. 1-15.

[10] Foley, Kathleen. “Pain Relief Into Practice: Rhetoric Without Reform.” (Alexandria: Journal of Clinical Oncology, 1995), p. 1-3

[11] Hla et. al. “Perception of Pediatric Pain: A Comparison of Postoperative Pain Assessments Between Child, Parent, Nurse, and Independent Observer.” (Melbourne: Pediatric Anesthesia. 2014) p. 1-5.

[12] Tsuboi et. al. “Nurses' perception of pediatric pain and pain assessment in the Japanese PICU.” (Tokyo: Pediatrics International, February 2023), p. 1-3, 10-12.

[13] Coleman, Doriane & Rosoff, Philip. “The Legal Authority of Mature Minors”. p. 1-3.

[14] Fleischman, Alan. Pediatric Ethics . p. 115.

[15] Callahan, Daniel. “Principlism and communitarianism.” (Garrison: The Hastings Center  Report, October 2003), p. 2.

[16] Fins, Joseph. “Mosaic Decisionmaking and Reemergent Agency after Severe Brain  Injury”. (Cambridge: Cambridge University Press, September 2017), p. 6.

Jonathan Tenenbaum

Third place winner of Voices in Bioethics' 2023 persuasive essay contest. 

Disclaimer: These essays are submissions for the 2023 essay contest and have not undergone peer review or editing.

Article Details

This work is licensed under a Creative Commons Attribution 4.0 International License .

Pain Assessment in Pediatric Settings Essay

Introduction.

Assessment of pain is one of the important issues in healthcare which helps to evaluate and analyze medical condition of a patient and his well being. In pediatric setting, pain management becomes a difficult point because of personal nature of this process and patients’ groups. The general approach of the pain is that pain behaviors are to be treated by systematic alterations in contingent reinforcement. Well behaviors are rewarded with praise, and even concrete reinforcers such as money, athletic shoes, and so on.

Pain centers also work to help them minimize reward for pain behavior. Even many highly resistant patients can show improvements in pain relief and can increase functional ability through an operant approach. Assessment of pain is complex due to the personal nature of the experience and other variables. It is particularly problematic in the pediatric setting

The main layer of literature proposes a theoretical interpretation of pain and its assessment techniques. Warfield and Baiwa (2004) underline pain management techniques and possible ways to relief pain. Melzack and Wall (2003) Marie (2002) underline that any experience of protracted pain may lead to some of the same problems as have been found in back pain: excessive narcotic use, deconditioning syndrome, and inability to work, to name a few.

Further, patients’ personality dispositions and emotional states, and histories may affect their perception of, and response to, pain and injury. Turk and Gatchel (2002) analyses and evaluate the causes of pain and possible treatment methods in different settings. The researchers found that the power of cognitive therapy techniques in affecting improvements for chronic pain patients, as well as the intuitive appeal of a cognitive perspective, has led to a proliferation of assessment devices and cognitive treatment techniques.

Another layer of literature is represented by case studies and researches devoted to a particular problem of pain management in different medical settings. Ducharme et al (2002) analyze and evaluate treatment methods applied to Children of Parents with brain injury. The researchers found that as pain persists, such overt, respondent pain behaviors inevitably produce certain responses by the patient and the social environment. Calhoun (2001) found that family members may rush to give the patient medication, the employer may give the patient time off from work with pay, or the patient may receive narcotic medications. Lebovits (2002) investigates that responses to the patient’s pain displays can have the effect of turning the “respondent” acute pain behavior into “operant” pain behavior.

In general, pain is an unfortunate daily experience for many individuals. Chronic pain, lasting 6 or more months, is suffered by approximately 30% of the U.S. population. These individuals wake up, function during the day, and go to sleep trying to keep pain at a minimum while, at the same time, maintaining some quality of life. They may be frequent visitors to the doctor and the pharmacy (Ducharme et al 2002).

When they find relief it is usually short-lived and comes at a cost, such as dependence on narcotic medications or complete limitation of activity. Pain often becomes the central point of their existence. All pain is disturbing, irritating, and distracting, but when it is experienced on a constant basis, these noxious characteristics can become intolerable. Individuals who experience chronic pain can become increasingly physically disabled and emotionally distraught. Pain can be experienced in almost every organ system of the body. It is associated with a huge range of physical diagnoses. In many of these conditions, invasive treatment may be a plausible approach to removing the physical source of the pain, or at least reducing its impact on the patient (Calhoun 2001).

Assessment of pain is complex due to the unique nature and feelings of a patient, especially a child. The case study organized by Smith (2005) shows that a special case is patients with communication difficulties. “Lacking the ability to differentiate between various sensations and needs, the same type of behavior that signals the need to toilet may emerge when a person experiences discrete physical pain. Each is experienced as form of stress that may erupt in behavioral symptoms” (p. 99).

Similar situations are typical for pediatric settings when children cannot clearly express and identify their pain and its causes. Clinicians and researchers (Melzack and Wall 2003; Warfield and Baiwa 2004) have defined a wide variety of processes involved in the cognitive response to pain signals. Some of these processes, such as positive outcome expectancies and strong beliefs in one’s ability to control pain, are associated with better overall emotional adjustment and improved functional ability in chronic pain patients (Calhoun 2001).

Assessment of pain is a complex issue because it involves emotional, cognitive, and environmental factors (Lebovits, 2002).. This very explosion of the cognitive perspective presents a number of problems. Integrative theories do not have these limitations of the other theoretical perspectives. Integrative theories begin with an understanding of the physiological mechanisms by which tissue damage is monitored, and the neuronal signals indicating tissue damage are transmitted to the brain. Integrative theories go on to include consideration of psychological mechanisms, but within a physiologic framework (Lebovits, 2002).

Emotional, cognitive, and environmental factors are postulated to affect the physical transmission of pain signals. Some of these psychological events can have an inhibitory effect of the transmission of signals, whereas others may increase signal transmission. The value of integrative models is that they are able to incorporate a wide range of physical and psychological research on pain into a single and relatively simple model of pain (Turk and Gatchel 2002).

The model implies that the impact of an injury or tissue damage can grow as the process moves from nociception to pain behavior. Similarly, perception of the pain signals may be distorted so that the pain may seem to be magnified. The patient’s suffering may be disproportionate to nociceptive input and pain perception. Finally, the behavioral expression of the injury may be so excessive that it dominates the patient’ life. The interaction of physical and psychological factors influences the pain process, determining the extent to which the patient’s life is disrupted by the injury or disease process (Warfield and Baiwa 2004).

In the pediatric setting, the assessment of pain is difficult and complex because the possibility always exists that the nurse might be mistaken, either factually (clinically or technically) or morally in their initial assessment of a situation. For instance, what might at first appear to be a ‘moral problem’ may turn out not to be a moral problem at all, but merely a problem of poor communication, misunderstanding, misinterpretation of the facts, ignorance of legal law or institutional policy, inappropriate legal law, inadequate institutional policy, or cultural unawareness (Warfield and Baiwa 2004).

One should observe how pain behaviors such as shifting weight, rubbing affected areas, and facial pain expressions vary through the course of the session. Particularly, observe differences in pain behavior when the patient’s attention is called to this behavior, versus when the patient is distracted.

In most pain syndromes “normal” pain behaviors have been described. Pain has a normal distribution throughout the body in each syndrome. Certain activities and diagnostic techniques, such as palpation, should elicit particular types of pain responses. This risk factor is identified to the extent that the patient’s pain reports are not consistent with the level of pain behavior displayed, or are inconsistent with “normal” complaints in the particular pain syndrome (Warfield and Baiwa 2004).

Clinical judgment can be exercised when the client’s number of risk factors is near threshold level. Such judgment can be used when the patient displays three to five of the medical risk factors just listed, or when the patient displays three to five of the psychological risk factors just listed (Smith, 2005). When using clinical judgment, the patient is moved from one side of the high-risk threshold to the other. Thus, the decision about surgical prognosis can be altered, based on factors observed, but not specifically listed previously. However, because clinical judgment can only be applied when patients fall into a narrow range of risk factors, the use of this technique basically ties the decision on surgical prognosis to specific criteria, while permitting the practitioner some clinical latitude (Melzack and Wall 2003).

Nurses need to be open-minded about the precise nature of the problem at hand when diagnosing or identifying a supposed moral problem. Credibility is strongest when one not only documents carefully the basis for decisions in specific cases, but also when each patient becomes a part of ongoing research on pain assessment. After all, this form can be completed quite rapidly and provides the scientific basis of all the practitioner’s decisions (Warfield and Baiwa 2004).

The following example shows that it is difficult for a nurse to assess a child condition and determine the causes of pain and physical state. The case (personal communication) involves a girl of 10 suffering moderately chest pain and shortness of breath. The electrocardiograph (ECG) showed a number of cardiac arrhythmias, all of which were suggestive of an acute condition warranting immediate specialised medical and nursing care (Smith, 2005). Upon further questioning, it was revealed that the girl was also suffering a mild pain in her left arm (a pain she had ‘never had before’). The pain improved, however, while she rested in the casualty department.

Her past medical history indicated no known heart disease or any previous incidence of chest pain. This was the first time she had ever experienced such symptoms — symptoms which were indicative of significant underlying cardiac disease (Smith, 2005). The case shows that for a child it is difficult to describe and analyze her physical conditions, and it’s a task of nurse to foresee possible consequences and ask a child about the nature of pain (Calhoun 2001).

In some situations even the most competent and compassionate of clinical assessments will not necessarily result in the identification of a satisfactory solution to the problem of the patient’s pain since the obvious ‘clinical solution’ is precluded by the moral demand to respect the patient’s autonomous wishes (Lebovits, 2002). For instance, if a patient is left psychogenically distressed (for example, emotionally distressed, anxious, depressed and even suicidal) or in a state of needless physical pain and/or disability as a result of his/her experiences (as a patient in a given health care setting) reflective commonsense tells us that this person’s interests have been violated and the person him/herself ‘harmed’. The patient uses “emotional” or “psychological” vocabulary, such as “I feel,” “stress,” or “pissed off.”

The client makes “vague references” to intense emotional states, such as, “let’s not go into that,” “you don’t want to know,” or “it took me a long time to understand that” (Calhoun 2001). The client’s body language or facial expression indicate intense emotions even though the client does not verbalize these. For nurses in pediatric setting , t he interview provides an opportunity, not only to gather verbalized information, but also to assess how the patient’s functioning and behavior are affected by pain and by interpersonal situations. One should observe how pain behaviors such as shifting weight, rubbing affected areas, and facial pain expressions vary through the course of the session (Smith, 2005).

In sum, assessment of pain is complex due to the personal nature of the experience. Because the patient’s presenting problem is medical in nature, it is advisable to begin the interview by asking the patient about the injury and current symptoms. This allows one to explore the patient’s knowledge about the medical basis of the injury. By empathically listening to the story of the pain and injury, one establishes a level of rapport that will later allow the patient to discuss more emotional and personal issues. Even the most defensive patient will often provide hints at emotional issues while discussing the medical aspects of the pain. The astute practitioner is alert for these hints and takes the opportunity to explore them.

• Ducharme, J. M., Davidson, A., Rushford, N. (2002). Treatment of Oppositional Behavior in Children of Parents with Brain Injury and Chronic Pain. Journal of Emotional and Behavioral Disorders, 10 (4), pp. 241-245.
• Calhoun, J. A. Pain Must Not Be Wasted. Reclaiming Children and Youth , 10 (1), pp. 15-18.
• Lebovits, A. (2002). Psychological Issues in the Assessment and Management of Chronic Pain. Annals of the American Psychotherapy Association 5 (3), pp. 19-23.
• Turk, D. C., Gatchel, R. J. (2002). Psychological Approaches to Pain Management, Second Edition: A Practitioner’s Handbook . The Guilford Press; 2 edition.
• Warfield, C. A., Baiwa, Z. H. (2004). Principles & Practice of Pain Management . McGraw-Hill Professional; 1 edition.
• Melzack, R., Wall, P. D. Handbook of Pain Management: A Clinical Companion to Textbook of Pain. Churchill Livingstone; 1 edition. 2003.
• Marie, B., S. (2002). Core Curriculum for Pain Management Nursing. Saunders; 1 edition.
• Chicago (A-D)
• Chicago (N-B)

IvyPanda. (2021, August 14). Pain Assessment in Pediatric Settings. https://ivypanda.com/essays/pain-assessment-in-pediatric-settings/

"Pain Assessment in Pediatric Settings." IvyPanda , 14 Aug. 2021, ivypanda.com/essays/pain-assessment-in-pediatric-settings/.

IvyPanda . (2021) 'Pain Assessment in Pediatric Settings'. 14 August.

IvyPanda . 2021. "Pain Assessment in Pediatric Settings." August 14, 2021. https://ivypanda.com/essays/pain-assessment-in-pediatric-settings/.

1. IvyPanda . "Pain Assessment in Pediatric Settings." August 14, 2021. https://ivypanda.com/essays/pain-assessment-in-pediatric-settings/.

Bibliography

IvyPanda . "Pain Assessment in Pediatric Settings." August 14, 2021. https://ivypanda.com/essays/pain-assessment-in-pediatric-settings/.

• Associations in the Everyday Practice of Pediatric Nurses
• Pediatric Pain Management
• Conflict Resolution in Pediatric Healthcare
• Nitrous Oxide Inhalation Sedation in Pediatric Dental Clinic
• The Mistakes Made by Nurses In Pediatric
• Comparative Analysis of Pediatric and General Medical Training
• Pediatric Influenza and Risk Factors
• Adult and Pediatric Emergency Rooms: Nurse Practitioners Role
• Prevention of Hospital-Acquired Infections Among Pediatric Patients
• Pediatric Advanced Registered Nurse Practitioner
• Hand Hygiene Workflow in Pediatric Settings
• Hospital-Acquired Infections: Quality Improvement
• Preterm Birth and Hypothermia
• The Issues of Infant Mortality and Morbidity
• Adolescent Sleep and the Impact of Technology Use

An official website of the United States government

The .gov means it's official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• Browse Titles

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Pain assessment.

Alexander M. Dydyk ; Sundeep Grandhe .

Affiliations

Last Update: January 29, 2023 .

• Continuing Education Activity

There are multiple tools used to help assess a patient's pain. These tools can be used to assess multiple types of pain, ranging from nociceptive pain to neuropathic. This activity outlines and reviews the pain assessment, and highlights the role of the interprofessional team in evaluating and treating patients who are experiencing pain.

• Identify the indications and contraindications of pain assessment.
• Describe the techniques for assessing pain.
• Outline the appropriate evaluation of the clinical significance of pain assessment.
• Review interprofessional team strategies for improving care coordination and communication to advance the assessment of pain and to improve patient outcomes.
• Introduction

Pain is the most common complaint seen in a primary care office. There are over 50 million Americans, 20% of all patients, that suffer from chronic pain in the United States. [1]  The prevalence of chronic pain is even higher in the elderly. [2]  With opioid use disorder on the rise, it is critical to treat a patient's pain in a logical manner adequately.

Part of the pain assessment is defining whether a patient's pain is either acute or chronic. When severe pain lasts longer than three months, it is generally considered to be chronic. Determining if the pain is acute or chronic pain is an important distinction because as pain transitions from acute to chronic, pain becomes centralized, or a function of the central nervous system rather than peripheral. Pain becomes maladaptive with hyperalgesia, and allodynia becoming more prevalent. The texture of the tissues becomes hypertonic, ropy, and cold. Pain is often more dull and achy rather than sharp.

How we assess pain has long-term implications for our patient's morbidity and mortality. With over 30% of patients reporting pain lasting longer than six months, providers should have multiple tools at their disposal to define a patient's pain to treat their symptoms better. An estimated 8% of adult patients and 6% of children suffer from chronic pain that causes significant limitations in function and quality of life. [1] [3]

Effective treatment modalities for acute, chronic, centralized, or neuropathic pain are often different. 10% of the United States population complain of neuropathic pain. This population may benefit from a serotonin-norepinephrine reuptake inhibitor (SNRI) such as duloxetine, as compared to ibuprofen for an acute injury. [4] [5]  Chronic pain is among the leading causes of disability and lost work hours in the United States. Billions of dollars are lost due to loss of productivity. Thus standardized pain assessment tools are an objective way of monitoring a patient's symptoms, as well as their recovery.

An important aspect of the pain assessment is in the acknowledgment of the influence of various comorbidities and psychosocial determinants of health that impact pain. Comorbid mood disorders lead to worsening pain, and the treatment of said mood disorder improves a patient's pain. Prior history of opioid dependence, IV drug use, sexual abuse, trauma, old age, chronic diseases, and economic disparity all contribute to a patient's pain. Cultural influences on pain also play a role. [6] [7] [8]

• Anatomy and Physiology

Acute pain is nociceptive pain. This type of pain originates in the peripheral nervous system, where pain receptors synapse in the dorsal horn of the spinal cord and travel along the spinothalamic tract until they synapse in the thalamus. When a pain signal reaches our central nervous system, action potentials fire. Once a threshold is achieved, pain is experienced. Separately, pain can be neuropathic or centralized.

As pain becomes chronic, over three to six months of acute pain, pain can become centralized. Centralized pain requires a lower threshold to experience pain. Decreased thresholds are problematic. Pain is an adaptive response to a painful stimulus. A lower threshold for pain subjectively means pain can be experienced from non-painful stimuli (allodynia), or mildly painful stimuli experienced can be experienced as severe pain (hyperalgesia). Centralized pain is a maladaptive form of pain.

Neuropathic pain is the dysfunction of the somatosensory tract of the nervous system, rather than the spinothalamic. [9] [4]  Centralized and neuropathic pain often coincide but are not mutually exclusive. Neuropathic pain can be both peripheral and centralized. Centralized and neuropathic pain are both considered gains in function (pain). They both play a role in the development of chronic pain. [10] [11] [12]

How we treat pain is a function of the pathophysiology of the type of patient's pain. Some types of pain respond to modulating neurotransmitters or ion channels, while others are more receptive to opioid neuroreceptors.

• Indications

Intuitively, pain is a subjective experience, and thus many elements of the biopsychosocial components during history taking are critical. A stoic patient with acute pancreatitis may rate their pain severity a four out of ten, while a more histrionic patient with wrist strain could state their pain is an eight out of ten. Neither patient is wrong, and it is a subjective measurement. [13]  Objective measures of pain, especially chronic pain, help create a standardized way to orient patients and providers to their pain, with the ultimate goal of improvement of pain and patient outcomes such as function and quality of life.

An essential first step in the pain assessment is distinguishing nociceptive pain from neuropathic. A sharp or throbbing pain is more likely to be acute nociceptive pain. Pain characterized as burning, shooting, pins, and needles, or electric shock-like point the differential towards a neuropathic origin of the patient's pain. [14] [15] [16]

• Contraindications

The various aspects of the patient's life may affect treatment decisions. For instance, pregnancy is often associated with low back pain, and pregnancy can complicate the choice of medication treatment options for chronic pain, particularly the use of opioids. [17]

It is critical to not focus solely on the numerical value of someone's pain. Often, it is necessary to prompt a patient to explain the numerical scale of pain. A 1/10 pain being a minor bump or bruise, while 10/10 pain being the worst pain they have ever experienced on par with giving birth or passing a kidney stone. [18]  If a patient complains of 9/10 pain, this does not mean they automatically warrant opioid analgesia. [19]  They may very well benefit from less potent analgesics tailored to treating the underlying cause.

To fully assess the location of a patient's pain, a body diagram map can be completed. Ankle sprains are solitary, acute injuries. Body diagrams may not be necessary in such a case. Localized pain is different than whole body pain. Yet, in a patient with multiple comorbid pain disorders such as fibromyalgia, centralized pain disorder, and rheumatoid arthritis, distinguishing between the numerous locations of a patient's pain, as well as factoring the radiation of their pain, is difficult. However, it is an essential part of guiding therapy. In a patient with widespread pain, a body diagram map helps the distinction between new pain complaints and chronic. Is the patient with multiple comorbidities experiencing a rheumatoid arthritis flare, or is it a reactivation of pain secondary to knee osteoarthritis? A body diagram helps to decipher multiple different types of pain.

A fibromyalgia survey can be used to help distinguish a new pain complaint from a patient's comorbid fibromyalgia as well.

Functional MRI and various imaging modalities can be helpful in a pain assessment. [20] [21]

Both the primary care provider and specialists often need to review previous records related to the patient's pain complaint in detail. Records usually include imaging, mental healthcare-related therapies such as cognitive-behavioral therapies, past surgical history, and previous medications used. For example, if a patient with neuropathic pain secondary to diabetic peripheral neuropathy had failed gabapentin therapy, the reason for the medication failure must be noted. Inquire if it was due to the side effect profile. Ask if gabapentin had caused too much sedation or if the medication failed to provide the expected pain relief. If the drug did not work, determine the dose before stopping. If the patient with diabetic peripheral neuropathy was on 300 mg twice a day of gabapentin, then the patient was only on a fraction of the maximal dose before stopping. Gabapentin's failure in the treatment of neuropathic pain usually is concluded after 1800 mg daily, not 600 mg in tolerating patients.

Furthermore, nonpharmacological therapies such as virtual reality, acupuncture, physical therapy, and invasive treatment modalities such as neuromodulation can be utilized. The patient's records need to be obtained. Failures and success of these various treatment modalities must be defined.

• Preparation

How a provider approaches their patient, their receptiveness, and the empathy they show can significantly impact patient outcomes. The relationship made between the provider and the patient has a lasting impact on the improvement of a patient's pain. Studies have shown that physician support and empathy improve pain and the wellbeing of patients. [22] [23]

• Technique or Treatment

There are multiple acronyms used to obtain the history of a patient's pain. Some of the most commonly used abbreviations are "COLDERAS" and "OLDCARTS. Both of these acronyms summarize the character, onset, location, duration exacerbating symptoms, relieving symptoms, radiation of pain, associated symptoms, and severity of illness.

A multidimensional assessment of a patient's pain and the severity of their pain can be completed. A Pain, Enjoyment, General Activity (PEG) tool can be used to aid the multidimensional assessment of patients in pain. [24]  The PEG score focuses on function and quality of life. A chronic pain patient who experiences daily 7/10 pain is treated with both pharmacological and nonpharmacological therapies. Following treatment, their pain is 5/10. A few points might not seem like a significant difference, but if their enjoyment and quality of life, as well as function, are improving, treatment may have had a profound impact on the patient's life. The PEG tool is scored 0 to 10 for each category. The higher the score, the worse the function and uncontrolled pain.

The Four-item Patient Health Questionnaire or PHQ-4 is a combination of the PHQ9 and GAD7 assessment tools used to evaluate depression and anxiety, respectively. [25]  The PHQ-4 should be used as a screening tool for all cases of chronic pain. If the score of the PHQ-4 is more significant than five, then a full GAD-7, PHQ-9, and the Primary Care PTSD screening tools are recommended. [26]

The Defense and Veterans Pain Rating Scale (DVRPS) is a five-item tool with a 0 to 10 out pain scale, as well as an assessment of the impact of pain on sleep, mood, stress, and activity levels. [27]

In children self-reporting a behavioral observation scales are used to assess pain. [28]  Age-based rating scales of pain can be used. Visual analogs are also often implemented. Typically visual analogs are done with pictures of faces in various degrees of distress. By adolescence, children usually can rate their pain on a numerical scale, similar to adults. [29]

The Pediatric Pain Questionnaire and the Adolescent and Pediatric Pain Tool are used to assess the location of a patient's pain as well. The patient is asked to draw on the body map where they feel pain. [30]  The ideal age group is age 10 for these tools.

Observational pain assessment tools are used in populations who cannot self-report. The facial expression, fussiness, and distractibility, ability to be consoled, verbal responsiveness, and motor control are observational findings used in such an assessment tool. Observational pain assessment in infants or young children can use the (r-FLACC) tool. [28] [31]  The tool is an acronym for Revised Face, Legs, Activity, Cry, Consolability. [32]  Multiple other validated tools can be used, the one that is better than another is the NAPI tool. However, multiple tools have been used and are validated. [33] [34] [35] [31]

Nonverbal children with neurologic impairment (NI) are a challenging population to assess pain. Caregivers are often needed to help determine changes in the patient's behavior. Grimacing, moaning, increased muscle tone, crying, arching, atypical behavior such as aggressive behavior are a few symptoms to monitor in this population. Nonverbal children with NI include the Revised Face, Legs, Activity, Cry, Consolability (r-FLACC) scale, and the Individualized Numeric Rating Scale (INRS). The assessment adds specific behavior for atypical presentations. [36] [34]

• Complications

A family history of mental health disorders, chronic pain disorders, or substance abuse puts patients at higher risk of developing chronic pain. [37] [38] [39]  

An overlooked aspect of the management of pain is the influence of sleep hygiene, stress, exercise, and diet play in the recovery of an injury.

Catastrophizing about pain can be a symptom of severe and debilitating pain. There is real fear associated with pain that can be all-consuming for a patient. Ironically, this hyperfocus on pain often makes the subjective experience of pain worse, not better. [40]

Underserved communities are at increased risk for the development of chronic pain, substance abuse, and opioid dependence. When assessing a patient's pain, it is essential to be mindful of the area of your practice. Multiple factors contribute to the increased risk, including limited access to care and socioeconomic status. Local culture in specific geographic regions has a much higher percentage of the population on chronic opioids. The approach to assessing pain also changes for adults, children, the disabled, and the elderly. [41] [42] [43]

Failure to complete physical therapy after only attending two sessions for shoulder pain is not the failure of treatment — moreover, its noncompliance. This is why it is critical to assess the effect of therapy. Stopping therapy because a patient does not wish to go to their appointments is very different than completing all sessions and continuing to have persistent pain. It is a complication of a poorly obtained pain assessment.

Observational assessment underestimates self-reported pain scores. [44]

Hunger and stress levels also impact pain severity. [45]

• Clinical Significance

The long-term impact of two to three days of acute, postoperative nociceptive pain, pales in comparison to the centralized pain and its long-term impact on a patient's quality of life. Part of the pain assessment is categorizing the type of pain the patient is experiencing. How the pain is described is high yield. Ask if the pain is burning or sharp and if it is constant or intermittent because the descriptors matter. Examination findings also increase the likelihood of one type of pain over another. If the patient is experiencing symptoms of allodynia or hyperalgesia, this points away from acute pain and suggests a centralized process. [46] [47]

Providers must discuss with the patient the expectations for therapy, as well as they need to teach patients about their pain. Various surgical procedures may put a patient at an increased rate of developing chronic pain. Breast surgery, for example, has a higher likelihood of chronic pain compared to knee placement. [48] [49]

Assessment of pain is not a one-time occurrence. It narrows the differential diagnosis. It is a way to monitor therapy, as well as changes to pain over time. Chronic pain disorder, although appropriate as a diagnosis in some circumstances, is not a blanket label for all patients experiencing prolonged pain. [50]  It is essential to treat comorbid health conditions in all pain complaints. It improves patient outcomes.

• Enhancing Healthcare Team Outcomes

An interprofessional team that provides a holistic and integrated approach to pain management can help achieve the best possible outcomes for the patient. If there is a specific underlying cause of a patient's pain, it must be determined. The role of the primary care providers in the management of acute and chronic pain, as well as the various comorbidities associated with pain, is essential. Specialists are often needed to manage various pain disorders. Neurologists, pain medicine specialists, orthopedic surgeons are but a few specialists who are a part of a pain assessment team. Furthermore, palliative care or supportive care medicine specialists, physical therapists, occupational therapists, and cognitive-behavioral therapists also play an integral role in pain assessment. Pain assessment tools can be used in an inpatient or outpatient setting and be incorporated into the management of multiple scenarios ranging from post-operative pain, palliative pain, acute injury, or chronic pain disorders. Adequate pain management in both an acute and chronic setting leads to better patient outcomes. It is critical to optimize a patient's care by managing their pain with various nonpharmacological, pharmacological, and interventional treatment approaches.

Collaboration, shared decision-making, and communication are key elements for a good outcome. The interprofessional care provided to the patient must use an integrated care pathway combined with an evidence-based approach to planning and evaluation of all joint activities. The earlier the signs and symptoms of a complication are identified, the better is the prognosis and outcome. The primary way to prevent chronic pain is adequate treatment and assessment of acute pain.

• Nursing, Allied Health, and Interprofessional Team Interventions

Various questionnaires should be administered at the beginning of each patient visit depending on the patient's age and associated comorbidities.

• Nursing, Allied Health, and Interprofessional Team Monitoring

Various pain assessment tools can be used upon each visit to monitor changes in pain over time, as well as responses to treatment.

• Review Questions
• Access free multiple choice questions on this topic.
• Comment on this article.

Disclosure: Alexander Dydyk declares no relevant financial relationships with ineligible companies.

Disclosure: Sundeep Grandhe declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Dydyk AM, Grandhe S. Pain Assessment. [Updated 2023 Jan 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

In this Page

Bulk download.

• Bulk download StatPearls data from FTP

Related information

• PMC PubMed Central citations
• PubMed Links to PubMed

Similar articles in PubMed

• Prescription of Controlled Substances: Benefits and Risks. [StatPearls. 2024] Prescription of Controlled Substances: Benefits and Risks. Preuss CV, Kalava A, King KC. StatPearls. 2024 Jan
• NP Safe Prescribing of Controlled Substances While Avoiding Drug Diversion. [StatPearls. 2024] NP Safe Prescribing of Controlled Substances While Avoiding Drug Diversion. Dydyk AM, Sizemore DC, Haddad LM, Lindsay L, Porter BR. StatPearls. 2024 Jan
• Florida Controlled Substance Prescribing. [StatPearls. 2024] Florida Controlled Substance Prescribing. Dydyk AM, Sizemore DC, Fariba KA, Sanghavi DK, Porter BR. StatPearls. 2024 Jan
• Review Screening Tools for Chronic Post-Surgical Pain [ 2021] Review Screening Tools for Chronic Post-Surgical Pain Wells C, McCormack S. 2021 Jan
• Review Serotonin and noradrenaline reuptake inhibitors (SNRIs) for fibromyalgia. [Cochrane Database Syst Rev. 2018] Review Serotonin and noradrenaline reuptake inhibitors (SNRIs) for fibromyalgia. Welsch P, Üçeyler N, Klose P, Walitt B, Häuser W. Cochrane Database Syst Rev. 2018 Feb 28; 2(2):CD010292. Epub 2018 Feb 28.

Recent Activity

• Pain Assessment - StatPearls Pain Assessment - StatPearls

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

Connect with NLM

National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894

Web Policies FOIA HHS Vulnerability Disclosure

Help Accessibility Careers

Help | Advanced Search

Electrical Engineering and Systems Science > Image and Video Processing

Title: segmentation of knee bones for osteoarthritis assessment: a comparative analysis of supervised, few-shot, and zero-shot learning approaches.

Abstract: Knee osteoarthritis is a degenerative joint disease that induces chronic pain and disability. Bone morphological analysis is a promising tool to understand the mechanical aspect of this disorder. This study proposes a 2D bone morphological analysis using manually segmented bones to explore morphological features related to distinct pain conditions. Furthermore, six semantic segmentation algorithms are assessed for extracting femur and tibia bones from X-ray images. Our analysis reveals that the morphology of the femur undergoes significant changes in instances where pain worsens. Conversely, improvements in pain may not manifest pronounced alterations in bone shape. The few-shot-learning-based algorithm, UniverSeg, demonstrated superior segmentation results with Dice scores of 99.69% for femur and 99.60% for tibia. Regarding pain condition classification, the zero-shot-learning-based algorithm, CP-SAM, achieved the highest accuracy at 66% among all models. UniverSeg is recommended for automatic knee bone segmentation, while SAM models show potential with prompt encoder modifications for optimized outcomes. These findings highlight the effectiveness of few-shot learning for semantic segmentation and the potential of zero-shot learning in enhancing classification models for knee osteoarthritis diagnosis.

Submission history

Access paper:.

• Download PDF
• Other Formats

References & Citations

• Google Scholar
• Semantic Scholar

BibTeX formatted citation

Bibliographic and Citation Tools

Code, data and media associated with this article, recommenders and search tools.

• Institution

arXivLabs: experimental projects with community collaborators

arXivLabs is a framework that allows collaborators to develop and share new arXiv features directly on our website.

Both individuals and organizations that work with arXivLabs have embraced and accepted our values of openness, community, excellence, and user data privacy. arXiv is committed to these values and only works with partners that adhere to them.

Have an idea for a project that will add value for arXiv's community? Learn more about arXivLabs .

SCOTT BRAGG, PharmD, SARAH TUCKER MARRISON, MD, PhD, AND SEAN HALEY, MD, MPH

Am Fam Physician. 2024;109(3):226-232

Author disclosure: No relevant financial relationships.

Diabetic peripheral neuropathy occurs in up to 50% of patients with diabetes mellitus and increases the risk of diabetic foot ulcers and infections. Consistent screening and clear communication are essential to decrease disparities in assessment of neuropathic symptoms and diagnosis. Physicians should address underlying risk factors such as poor glycemic control, vitamin B 12 deficiency, elevated blood pressure, and obesity to reduce the likelihood of developing neuropathy. First-line drug therapy for painful diabetic peripheral neuropathy includes duloxetine, gabapentin, amitriptyline, and pregabalin; however, these medications do not restore sensation to affected extremities. Evidence for long-term benefit and safety of first-line treatment options is lacking. Second-line drug therapy includes nortriptyline, imipramine, venlafaxine, carbamazepine, oxcarbazepine, topical lidocaine, and topical capsaicin. Periodic, objective monitoring of medication response is critical because patients may not obtain desired pain reduction, adverse effects are common, and serious adverse effects can occur. Opioids should generally be avoided. Nondrug therapies with low- to moderate-quality evidence include exercise and neuromodulation with spinal cord stimulation or transcutaneous electrical nerve stimulation. Peripheral transcutaneous electrical nerve stimulation is well tolerated and inexpensive, but benefits are modest. Other treatments, such as acupuncture, alpha-lipoic acid, acetyl-L-carnitine, cannabidiol, and onabotulinumtoxinA need further study in patients with diabetic peripheral neuropathy.

Diabetic peripheral neuropathy is the most common complication of diabetes mellitus, affecting up to 50% of patients with diabetes. 1 It commonly presents as distal symmetric polyneuropathy with a stocking-and-glove distribution and a loss of sensation that may be painful or asymptomatic, starting in the toes and moving proximally. Diabetic peripheral neuropathy may result in a loss of protective sensation and cascade into the development of foot ulcers, wounds, infections, and tissue necrosis. 2 , 3

Primary Prevention

Prevention of diabetic peripheral neuropathy is essential because there is no cure for neuropathy; treatments should focus on symptom management and slowing disease progression. 2 , 4 – 6 Reducing the risk of amputations and protecting extremities from trauma continue to be paramount. 3 , 6 Glycemic control remains the primary mechanism to prevent diabetic peripheral neuropathy, with greater benefit from early optimization of glucose control. In patients with type 1 diabetes, intensive glycemic control with an A1C goal of approximately 7% reduces the risk of symptomatic neuropathy by up to 60%. 7 Only modest reductions in neuropathy risk occur with intensive glycemic control in patients with type 2 diabetes. 8 Assessment for vitamin B 12 deficiency may be valuable because a deficiency increases the risk of neuropathy, may lead to a misdiagnosis of diabetic peripheral neuropathy, and can be treated with supplementation. Initial vitamin B 12 levels should be measured in individuals with absorption issues (e.g., after bariatric surgery), with autoimmune disease, who eat a strict vegetarian diet, or who take metformin. 9 , 10 Maintaining a systolic blood pressure of 140 mm Hg or lower and low-density lipoprotein cholesterol of 100 mg per dL (2.6 mmol per L) or lower can decrease the development of diabetic peripheral neuropathy. 11

The American Diabetes Association Diabetes Standards of Care guidelines recommend diabetic peripheral neuropathy screening with monofilament testing, but this practice has poor sensitivity for detecting peripheral neuropathy. 6 , 12 Diabetic peripheral neuropathy is a clinical diagnosis and a diagnosis of exclusion, and other assessment factors (e.g., neurologic, skin, vascular, foot deformities) should be considered. 4 , 6 Additionally, a patient's cultural background should be considered when screening because Black and Hispanic patients report difficulty communicating with physicians about their symptoms and have a lower rate of diabetic peripheral neuropathy diagnosis. 13 Further research may highlight drivers of these disparities, but communication in a patient's preferred language and verification of understanding are key.

Secondary Prevention

Multiple tools are available for assessing limitations secondary to neuropathy; the Overall Neuropathy Limitations Scale is one of the available tools that can assist with management decisions ( https://www.mdcalc.com/calc/10242/overall-neuropathy-limitations-scale-onls ). Primary prevention efforts (e.g., intensive glycemic control, comorbidity management) may reduce long-term pain; however, patients with rapid, significant glucose improvements may paradoxically experience short-term increases in pain from treatment-induced neuropathy of diabetes. 6 , 14

Increased emphasis on foot care and preventing diabetic foot ulcers and amputations should occur. 3 Individuals at high risk (e.g., patients receiving dialysis, having Charcot foot or other structural foot deformities, having a history of ulcers or peripheral arterial disease) should be referred to foot care specialists; these specialists can advise the patient about specialized footwear, which may be valuable. 3 Individuals with foot ulcerations should receive prompt treatment and frequent surveillance to prevent progression. 3 , 6

Correction of underlying risk factors should be addressed to minimize the need to treat diabetic peripheral neuropathy. Treatment with vitamin B 12 is beneficial in individuals with a deficiency but not in individuals with adequate levels. 9 For patients with severe obesity (body mass index 35 kg per m 2 or greater), weight loss interventions may improve quality-of-life scores. 15 Tobacco cessation should also be a priority to slow the progression of neuropathy and reduce other complications of diabetes. 16

A multimodal treatment plan should be developed for individuals with painful diabetic peripheral neuropathy. Reducing pain is the primary objective because current therapy does not reverse previous nerve damage. 6 Four drug treatments have been approved by the U.S. Food and Drug Administration for diabetic peripheral neuropathy: duloxetine (Cymbalta), pregabalin (Lyrica), tapentadol (available as brand Nucynta extended-release), and capsaicin patch (Qutenza). Many treatments, however, have been used successfully off-label. Nondrug therapy comprises neuromodulatory therapy and exercise. 2 , 6 , 17 Combination treatment with first-line therapies from different drug classes may be reasonable for patients who have inadequate pain management while taking monotherapy. 18 Figure 1 provides guidance for treatment in patients with diabetic peripheral neuropathy. 2 , 6 , 17 , 19 – 22

ANTIDEPRESSANTS

Duloxetine, a serotonin-norepinephrine reuptake inhibitor, is first-line therapy and the most studied antidepressant for patients with diabetic peripheral neuropathy. A 2023 Cochrane review concluded that it is the only antidepressant with adequate data in patients with chronic pain. 23 With duloxetine, the risk ratio (RR) was 1.73 (95% CI, 1.44 to 2.08) for a 50% or greater reduction in pain at 12 weeks. 24 The benefit of duloxetine plateaus at 40 to 60 mg per day, with no greater effect at 120 mg per day and no effect at 20 mg per day. 24 Duloxetine may make several conditions worse (e.g., uncontrolled hypertension, cardiovascular disease, hepatic impairment) or have more potent effects in patients with renal insufficiency, requiring dose adjustment, frequent monitoring, or drug avoidance. 25

In a few head-to-head trials, duloxetine has been compared with pregabalin and amitriptyline in patients with diabetic peripheral neuropathy. In a 12-week study with 804 participants, more individuals taking duloxetine had a 50% or greater reduction in pain (38%) than those taking pregabalin (26%; RR = 1.46; 95% CI, 1.19 to 1.80). 24 Similar rates of at least a 50% reduction in pain were seen with duloxetine (59%) and amitriptyline (55%) in a six-week crossover study of 62 participants. 24 Dry mouth was a more common adverse effect when taking amitriptyline vs. duloxetine (55% vs. 24%; P < .01). 26

Amitriptyline is another antidepressant commonly prescribed for painful diabetic peripheral neuropathy, although its magnitude of effect remains unclear. A 2015 Cochrane review noted that amitriptyline studies were of weak quality and had high risk of bias. 27 Although the studies are flawed, amitriptyline should remain as a first-line treatment, with continued monitoring for effectiveness and adverse effects. 27

Use of other antidepressants may be reasonable, but evidence of benefit for patients with painful diabetic peripheral neuropathy is limited. Data for venlafaxine and milnacipran (available as brand Savella) comprise low-quality strials showing limited benefits. 28 , 29 As a result, these treatments should be reserved for patients who are unable to tolerate or have poor response to other options. Similarly, because of weak, low-quality evidence, use of nortriptyline and imipramine should be more reserved considering the questionable benefits and significant adverse-effect burden. 30 , 31 Bupropion is another antidepressant with one low-quality trial in a six-week study that shows its use could improve pain scores. 32

ANTICONVULSANTS

Pregabalin and gabapentin are first-line treatment options for diabetic peripheral neuropathy, with pregabalin being slightly preferred. 33 Higher pregabalin doses are more effective; a 50% reduction in pain occurred in 31% of patients taking 300 mg daily vs. 41% of patients taking 600 mg daily. 34 The overall quality of data supporting gabapentin is weaker but showed a similar finding that higher doses (at least 1,200 mg per day) are needed to obtain a 50% reduction in pain in 38% of patients. 6 , 35 Few head-to-head studies have been conducted, but a 2022 study with 100 patients showed that pregabalin had less sleep interference and a greater difference in global impressions of change compared with gabapentin. 33

Initially starting with lower doses of pregabalin and gabapentin and taking doses at bedtime are reasonable to avoid oversedation 2 , 34 , 35 ( Table 1 2 , 19 , 24 , 25 , 32 , 34 – 38 ) . Reduced doses to minimize adverse effects may be needed in patients with renal insufficiency and in older individuals. 2 , 19 , 25

A 2022 propensity-matched, retrospective study has called into question the safety of long-term use of gabapentin and pregabalin. 39 In the study with 210,064 patients with diabetic peripheral neuropathy, patients taking gabapentin or pregabalin had a higher risk of cardiovascular events at five years compared with individuals not using either drug. Cardiovascular events included pulmonary embolism (hazard ratio [HR] = 1.50), peripheral vascular disease (HR = 1.37), stroke (HR = 1.31), myocardial infarction (HR = 1.25), and heart failure (HR = 1.14). 39 Confounding variables could have contributed to these results, and further studies are warranted to ensure that pregabalin and gabapentin are safe long-term treatments.

Besides gabapentinoids, carbamazepine and oxcarbazepine have shown improvements in diabetic peripheral neuropathy pain. Use of carbamazepine and oxcarbazepine should be reserved for patients with pain refractory to first-line options because of concerns with tolerability, serious adverse effects, and increased monitoring demands. Follow-up within one to two weeks and then every few months for repeat laboratory testing is critical for minimizing adverse effects 36 , 37 ( Table 1 2 , 19 , 24 , 25 , 32 , 34 – 38 ) . Other anticonvulsants (e.g., lacosamide [Vimpat], lamotrigine, topiramate, valproic acid, zonisamide) have been studied in patients with neuropathy but have not shown adequate benefit. 40 – 44

TOPICAL MEDICATIONS

Topical lidocaine and capsaicin are second-line agents with less robust data but fewer adverse effects. Lidocaine is widely available as a 4% cream or 5% patch that can be applied three times daily. A moderate-quality study (n = 204) comparing lidocaine 5% medicated plaster with pregabalin in patients with diabetic peripheral neuropathy showed comparable rates of patients obtaining at least 50% pain relief (40.4% vs. 37.2%). 45 Capsaicin is administered as a 0.075% cream four times a day or as an 8% patch (Qutenza) applied to a painful area every three months. Treatment with capsaicin 0.075% cream has weak evidence of benefit but is more affordable than the 8% patch. 6 , 20 , 25 The capsaicin 8% patch was studied in one high-quality trial (n = 468) vs. standard care alone, which showed that approximately 10% more participants were much or very much improved at eight to 12 weeks. 38 The capsaicin 8% patch can be used only in a physician's office and may increase pain in a minority of patients. 25 Lidocaine and capsaicin should not be applied to broken skin.

A 2013 Cochrane review (14 trials, n = 845) of studies of 12-week duration or shorter evaluated the use of opioids for treatment of neuropathic pain. Data from these studies demonstrated improvement in pain in 57% of participants receiving an opioid vs. 34% of those receiving a placebo, with a number needed to treat of 6 (95% CI, 3 to 50). However, the evidence was rated as low quality because the studies showed a high risk of bias. 46

Because of safety concerns, use of traditional opioids is often avoided in patients with diabetic peripheral neuropathy; however, tramadol and tapentadol are synthetic, centrally acting mu opioid agonists with serotonin-norepinephrine reuptake inhibitor activity, making them theoretically more helpful for treating diabetic peripheral neuropathy pain. 2 , 47 , 48 A Cochrane review of six double-blind trials (n = 438) of tramadol demonstrated a number needed to treat of 5 (95% CI, 2.9 to 8.8) for one additional participant to experience a 50% pain reduction. 47 Extended-release tapentadol (available as brand Nucynta extended-release) was approved by the U.S. Food and Drug Administration based on a 12-week double-blind randomized trial (n = 395) in which treatment demonstrated a 50% reduction in pain in 34.9% of patients ( P < .001) vs. placebo. 48

Any benefits of opioids should be weighed against long-term harmful effects (e.g., addiction, respiratory depression, tolerance, hyperalgesia). The American Academy of Neurology and the American Diabetes Association guidelines recommend avoiding opioids, including tramadol and tapentadol, for management of diabetic peripheral neuropathy. 6 , 20

OTHER MEDICATIONS

Alpha-lipoic acid, an antioxidant, is a safe and tolerable option for treating diabetic peripheral neuropathy. In a 2022 systematic review of eight studies (n = 1,500), use of alpha-lipoic acid demonstrated mixed results, with three trials showing benefit and five trials showing no notable effect. 49 Minimal benefits occurred when alpha-lipoic acid was used orally, whereas intravenous administration showed more consistent pain improvements. 2 , 49

Other treatments have limited evidence of benefit. A 2019 Cochrane review looked at acetyl-L-carnitine in four studies with 907 participants but concluded that the current evidence was inconclusive for supporting the reduction of pain. 50 Preliminary studies show that other treatments such as onabotulinumtoxinA (available as brand Botox) and cannabidiol (over the counter) have benefit, but high-quality studies are needed. 19

NONPHARMACOLOGIC THERAPY

Exercise can improve pain and function in patients with diabetic peripheral neuropathy. The ideal duration and type of exercise has yet to be identified; aerobic, resistance, and balance exercise have all shown benefits. 22 Adapting an individual's exercise regimen may be necessary to improve exercise tolerance and minimize injury concerns.

Several neuromodulatory strategies (e.g., spinal cord stimulation, transcutaneous electrical nerve stimulation) have demonstrated benefit for diabetic peripheral neuropathy, but the benefits are based on low-quality evidence. Spinal cord stimulation has demonstrated only potential benefit in case-control studies; possible limitations include adverse effects, expense, and surgical complications. 17 Peripheral transcutaneous electrical nerve stimulation therapy has been studied in moderate-quality prospective trials with modest benefit compared with electromagnetic nerve stimulation with no serious adverse effects. Considering its safety and low cost, treatment with transcutaneous electrical nerve stimulation is preferable compared with other neuromodulatory techniques. 21

Acupuncture has been evaluated; however, the most common outcome evaluated is nerve conduction velocity. Future acupuncture studies focused on patient-oriented outcomes are needed. 51

This article updates previous articles on this topic by Snyder, et al. 2 ; Lindsay, et al. 5 ; and Aring, et al. 52

Data Sources: Essential Evidence Plus and PubMed Clinical Queries were searched to identify systematic reviews, meta-analyses, and randomized trials. Key words included diabetic peripheral neuropathy, glycemic management, nonpharmacologic treatment, primary and secondary prevention, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, anticonvulsants, and topical medications. The Cochrane Database, DynaMed, and UpToDate were also searched for treatments studied in the context of diabetic peripheral neuropathy. Lexicomp was used to confirm dosing, titration, and adverse effect profiles. American Family Physician review articles and guidelines from the American Diabetes Association and American Academy of Neurology were consulted. Use of race/ethnicity was considered when writing the introduction/prevention section because disparities in diagnosis exist. No differences in treatment benefit were seen across these variables in studies we reviewed, so race/ethnicity/sexual orientation was not discussed in the treatment section. Search dates: April 30, May 3, July 2 and 20, 2023; January 18, 2024.

Callaghan BC, Cheng HT, Stables CL, et al. Diabetic neuropathy: clinical manifestations and current treatments. Lancet Neurol. 2012;11(6):521-534.

Snyder MJ, Gibbs LM, Lindsay TJ. Treating painful diabetic peripheral neuropathy: an update. Am Fam Physician. 2016;94(3):227-234.

Matheson EM, Bragg SW, Blackwelder RS. Diabetes-related foot infections: diagnosis and treatment. Am Fam Physician. 2021;104(4):386-394.

Castelli G, Desai KM, Cantone RE. Peripheral neuropathy: evaluation and differential diagnosis. Am Fam Physician. 2020;102(12):732-739.

Lindsay TJ, Rodgers BC, Savath V, et al. Treating diabetic peripheral neuropathic pain. Am Fam Physician. 2010;82(2):151-158.

American Diabetes Association Professional Practice Committee. 12. Retinopathy, neuropathy, and foot care: standards of care in diabetes—2024. Diabetes Care. 2024;47(suppl 1):S231-S243.

Nathan DM, Genuth S, Lachin J, et al.; Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329(14):977-986.

Ang L, Jaiswal M, Martin C, et al. Glucose control and diabetic neuropathy: lessons from recent large clinical trials. Curr Diab Rep. 2014;14(9):528.

Pratama S, Lauren BC, Wisnu W. The efficacy of vitamin B 12 supplementation for treating vitamin B 12 deficiency and peripheral neuropathy in metformin-treated type 2 diabetes mellitus patients: a systematic review. Diabetes Metab Syndr. 2022;16(10):102634.

Langan RC, Goodbred AJ. Vitamin B 12 deficiency: recognition and management. Am Fam Physician. 2017;96(6):384-389.

Bashir M, Elhadd T, Dabbous Z, et al. Optimal glycaemic and blood pressure but not lipid targets are related to a lower prevalence of diabetic microvascular complications. Diabetes Metab Syndr. 2021;15(5):102241.

Wang F, Zhang J, Yu J, et al. Diagnostic accuracy of monofilament tests for detecting diabetic peripheral neuropathy: a systematic review and meta-analysis. J Diabetes Res. 2017;2017:8787261.

Eichholz M, Alexander AH, Cappelleri JC, et al. Perspectives on the impact of painful diabetic peripheral neuropathy in a multicultural population. Clin Diabetes Endocrinol. 2017;3:12.

Gibbons CH, Freeman R. Treatment-induced neuropathy of diabetes: an acute, iatrogenic complication of diabetes. Brain. 2015;138(pt 1):43-52.

Callaghan BC, Reynolds EL, Banerjee M, et al. Dietary weight loss in people with severe obesity stabilizes neuropathy and improves symptomatology. Obesity (Silver Spring). 2021;29(12):2108-2118.

Voulgari C, Katsilambros N, Tentolouris N. Smoking cessation predicts amelioration of microalbuminuria in newly diagnosed type 2 diabetes mellitus: a 1-year prospective study. Metabolism. 2011;60(10):1456-1464.

Enders J, Elliott D, Wright DE. Emerging nonpharmacologic interventions to treat diabetic peripheral neuropathy. Antioxid Redox Signal. 2023;38(13–15):989-1000.

Tesfaye S, Sloan G, Petrie J; OPTION-DM trial group. Comparison of amitriptyline supplemented with pregabalin, pregabalin supplemented with amitriptyline, and duloxetine supplemented with pregabalin for the treatment of diabetic peripheral neuropathic pain (OPTION-DM): a multicentre, double-blind, randomised crossover trial. Lancet. 2022;4000(10353):680-690.

Mu A, Weinberg E, Moulin DE, et al. Pharmacologic management of chronic neuropathic pain: review of the Canadian Pain Society consensus statement. Can Fam Physician. 2017;63(11):844-852.

Price R, Smith D, Franklin G, et al. Oral and topical treatment of painful diabetic polyneuropathy: practice guideline update summary: report of the AAN Guideline Subcommittee. Neurology. 2022;98(1):31-43.

Zeng H, Pacheco-Barrios K, Cao Y, et al. Non-invasive neuromodulation effects on painful diabetic peripheral neuropathy: a systematic review and meta-analysis. Sci Rep. 2020;10(1):19184.

Hernández-Secorún M, Vidal-Peracho C, Márquez-Gonzalvo S, et al. Exercise and manual therapy for diabetic peripheral neuropathy: a systematic review. Appl Sci. 2021;11(12):5665.

Birkinshaw H, Friedrich CM, Cole P, et al. Antidepressants for pain management in adults with chronic pain: a network meta-analysis. Cochrane Database Syst Rev. 2023(5):CD014682.

Lunn MPT, Hughes RAC, Wiffen PJ. Duloxetine for treating painful neuropathy, chronic pain or fibromyalgia. Cochrane Database Syst Rev. 2014(1):CD007115.

Lexicomp. Accessed July 20, 2023. https://online.lexi.com

Kaur H, Hota D, Bhansali A, et al. A comparative evaluation of amitriptyline and duloxetine in painful diabetic neuropathy: a randomized, double-blind, cross-over clinical trial. Diabetes Care. 2011;34(4):818-822.

Moore RA, Derry S, Aldington D, et al. Amitriptyline for neuropathic pain in adults. Cochrane Database Syst Rev. 2015(7):CD008242.

Gallagher HC, Gallagher RM, Butler M, et al. Venlafaxine for neuropathic pain in adults. Cochrane Database Syst Rev. 2015(8):CD011091.

Derry S, Phillips T, Moore RA, et al. Milnacipran for neuropathic pain in adults. Cochrane Database Syst Rev. 2015(7):CD011789.

Derry S, Wiffen PJ, Aldington D, et al. Nortriptyline for neuropathic pain in adults. Cochrane Database Syst Rev. 2015(1):CD011209.

Hearn L, Derry S, Phillips T, et al. Imipramine for neuropathic pain in adults. Cochrane Database Syst Rev. 2014(5):CD010769.

Semenchuk MR, Sherman S, Davis B. Double-blind, randomized trial of bupropion SR for the treatment of neuropathic pain. Neurology. 2001;57(9):1583-1588.

Arvinth A, Suganya E. Comparison of efficacy of gabapentin versus pregabalin in patients of painful diabetic peripheral neuropathy—a randomized, open label, and parallel group study. Natl J Physiol Pharm Pharmacol. 2022;12(11):1901-1906.

Derry S, Bell RF, Straube S, et al. Pregabalin for neuropathic pain in adults. Cochrane Database Syst Rev. 2019(1):CD007076.

Wiffen PJ, Derry S, Bell RF, et al. Gabapentin for chronic neuropathic pain in adults. Cochrane Database Syst Rev. 2017(6):CD007938.

Wiffen PJ, Derry S, Moore RA, et al. Carbamazepine for chronic neuropathic pain and fibromyalgia in adults. Cochrane Database Syst Rev. 2014(4):CD005451.

Zhou M, Chen N, He L, et al. Oxcarbazepine for neuropathic pain. Cochrane Database Syst Rev. 2017(12):CD007963.

Derry S, Rice AS, Cole P, et al. Topical capsaicin (high concentration) for chronic neuropathic pain in adults. Cochrane Database Syst Rev. 2017(1):CD007393.

Pan Y, Davis PB, Kaebler DC, et al. Cardiovascular risk of gabapentin and pregabalin in patients with diabetic neuropathy. Cardiovasc Diabetol. 2022;21(1):170.

Hearn L, Derry S, Moore RA. Lacosamide for neuropathic pain and fibromyalgia in adults. Cochrane Database Syst Rev. 2012(2):CD009318.

Wiffen PJ, Derry S, Moore RA. Lamotrigine for chronic neuropathic pain and fibromyalgia in adults. Cochrane Database Syst Rev. 2013(12):CD006044.

Moore RA, Wiffen PJ, Derry S, et al. Zonisamide for neuropathic pain in adults. Cochrane Database Syst Rev. 2015(1):CD011241.

Gill D, Derry S, Wiffen PJ, et al. Valproic acid and sodium valproate for neuropathic pain and fibromyalgia in adults. Cochrane Database Syst Rev. 2011(10):CD009183.

Wiffen PJ, Derry S, Lunn MPT, et al. Topiramate for neuropathic pain and fibromyalgia in adults. Cochrane Database Syst Rev. 2013(8):CD008314.

Baron R, Mayoral V, Leijon G, et al. 5% lidocaine medicated plaster versus pregabalin in post-herpetic neuralgia and diabetic polyneuropathy: an open-label, non-inferiority two-stage RCT study. Curr Med Res Opin. 2009;25(7):1663-1676.

McNicol ED, Midbari A, Eisenberg E. Opioids for neuropathic pain. Cochrane Database Syst Rev. 2013(8):CD006146.

Duehmke RM, Derry S, Wiffen PJ, et al. Tramadol for neuropathic pain in adults. Cochrane Database Syst Rev. 2017(6):CD003726.

Hagedorn JM, Engle AM, George TK, et al. An overview of painful diabetic peripheral neuropathy: diagnosis and treatment advancements. Diabetes Res Clin Pract. 2022;188:109928.

Abubaker SA, Alonazy AM, Abdulrahman A. Effect of alpha-lipoic acid in the treatment of diabetic neuropathy: a systematic review. Cureus. 2022;14(6):e25750.

Rolim LC, da Silva EM, Flumignan RL, et al. Acetyl-L-carnitine for the treatment of diabetic peripheral neuropathy. Cochrane Database Syst Rev. 2019(6):CD011265.

Yu B, Li M, Huang H, et al. Acupuncture treatment of diabetic peripheral neuropathy: an overview of systematic reviews. J Clin Pharm Ther. 2021;46(3):585-598.

Aring AM, Jones DE, Falko JM. Evaluation and prevention of diabetic neuropathy. Am Fam Physician. 2005;71(11):2123-2128.

Continue Reading

More in AFP

Copyright © 2024 by the American Academy of Family Physicians.

This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.  See permissions  for copyright questions and/or permission requests.

Copyright © 2024 American Academy of Family Physicians. All Rights Reserved.

• Newsletters
• Account Activating this button will toggle the display of additional content Account Sign out

I Thought I Was Too Young to Get Shingles. I Learned the Hard Way.

If you’re over 50, get the vaccine..

A little more than two weeks ago, I took a red-eye home with my then-11-year-old daughter from a perfect winter break trip to Disneyland. It was more fun than I could have imagined, even with the eternal lines, ride breakdowns, and lack of vegetables. We rode every roller coaster in the day and the dark, ate uncountable clouds of cotton candy, and generally marveled at how clean everything was. (We live in Brooklyn, after all.)

But on the flight back from California, I could feel that something was weird with my leg. I didn’t think too much about it—I was on an airplane! But by the time we walked into our apartment around 7 a.m., I knew that something was wrong. The whole inside of my right thigh was sore. There wasn’t a lump, but thanks to having, well, ample thighs that love to connect with each other, I was very uncomfortable, and concerned.

On Monday morning, I woke up with a new symptom: an intermittent, painful, pins-and-needles sensation spreading down the front of my right thigh. I also had a little red blotch of skin, but as I said, my thighs rub together, so maybe it was nothing? I had previously booked a yoga class for that morning and showed up to it (on Zoom), despite my discomfort. My teacher suggested I talk to a doctor right away in case it was a blood clot. That hadn’t even occurred to me. I booked a virtual urgent care appointment with the doctors at NYU—the advances in apps, scheduling, and access have made moments like this so much easier—and spoke to someone later that morning. She doubted a clot but suspected I had pinched a nerve while walking so much at Disneyland.

Tuesday, everything was worse. More pain, and in my hip too. It was hard to walk. I made an appointment to see my primary care doctor the next morning. To get to sleep, I took half an old Percocet left over from a friend’s C-section.

But the next day at the doctor, I downplayed everything. “I feel a lot better today!” I told her. I thought it was true, but maybe I was wishing? It was my daughter’s birthday. I had to be fine, right? My doctor agreed with the one from the virtual appointment: some kind of nerve aggravation. She suggested ibuprofen.

By Thursday morning, I had a rash all over my right leg, above the knee. I had therapy (also on Zoom) at 8:30, and I told my therapist what was going on. Nicole winced. “It sounds like shingles,” she said.

Anyone who had chickenpox as a child can get shingles as an adult; the virus lives in us forever. That’s why it’s so beautiful that kids can get chickenpox vaccines now—that means they won’t get shingles later in life. I had a very mild case of chickenpox as a kid—like, maybe three or four spots. But that doesn’t lessen the chance of getting shingles. Most believe that stress is a contributor . Although I had a beautiful time at Disneyland, the travails of raising a middle schooler have definitely had an impact on my stress level (and surely so has the overall state of the world). And while shingles is more of a concern for adults over 50, it has, in recent decades, risen among younger people , according to the Centers for Disease Control and Prevention, something doctors have noticed too .

Still, when Nicole suggested shingles, I barely heard her. Shingles is for old people and super painful , I thought. I’m only 48. Plus, my leg was sensitive to the touch, but the splotches weren’t killing me or anything. I took a picture of the new rash on my leg and sent it to my doctor. The response was almost immediate. “Call the office,” the voicemail said.

That afternoon, I had my third appointment of the week, a virtual one with an RN who works with my primary care doctor. We were on for barely 30 seconds before it was confirmed: “I am not seeing you in person, but … I think you have shingles. Did you have pain on the inside of your thigh?” She listed all my symptoms. She prescribed antiviral medication and told me to start it right away.

I regretted that it had taken four days to sort out what was wrong with me—and have continued to regret that. But I hoped maybe I’d headed off the worst at the pass. I hadn’t.

It turns out shingles is super painful—and way worse than I had imagined. I’d thought it was, like, a big, red, unsightly, blistery rash that was painful. No. It’s “this is a virus attacking your nerves” painful.

Also, I thought everyone said it was so painful in part because old people got it, and old people are weaker than younger people. As my symptoms worsened, I wondered how people with real nerve problems manage to get through their days. It hurt to wear pants. It hurt to stand up. Sometimes, I wished I had gotten shingles on my face, or my head, instead of my leg; maybe that would be, ironically, less intrusive. I did not want to leave the house, and mostly didn’t. I burst into tears, frequently, because there was nothing else to do. Occasionally, I could create some distance from the pain by immersing myself in Survivor , but alas, that was only temporary.

I am writing as if this is the past tense, but it is very much my present. This morning, two weeks into having shingles, I scheduled another virtual urgent care visit. The lovely doctor on the other end told me he would prescribe me gabapentin, which sounds like a wonder drug the more I learn about it. It will help the pain, especially as I increase my dose. Its main side effects are to help with sleep (yes, please!) and ease anxiety (also yes, please).

Disappointingly, my prescription came with a reality check that this shingles pain will last weeks—or months. (Cue more tears.) I was hoping to use this spring to get in shape, get sunshine, get … happy. All that’s on hold until I can ease the pain and not be a self-pitying basket case.

Earlier in my shingles journey, I posted on Instagram, begging my friends over 50—who can easily qualify for the shingles vaccine—to go get the shot. And so I am asking you to do the same, even though I don’t know you. If you aren’t 50 but have a vulnerable immune system or are under lots of stress, it might be worth talking to your primary care provider about your options. I thought I was extremely unlikely to get shingles. But now I’ve heard about friends in their 20s and 30s getting it. We are all vulnerable! But maybe I can help you be less so by sharing.