Throw the Pain Scale Out the Window

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Literally, sayonara pain scale. Hello tolerance! I stopped using the pain scale several years ago. Patients would struggle to find the “right” answer as if there is one. I would hear clinicians question the validity of a patients high pain rating and even suggest the need to go to the emergency department if their pain was *actually* that high. I would imagine this furthered the patient’s experience of not feeling believed. If you choose to use a pain scale, accept their answer. In Abby Norman’s book “Ask Me About My Uterus: A Quest To Make Doctors Believe in Women’s Pain” (read the excerpt here), she recounts her own initiation into chronic pain. She also explains how the modern pain scale was developed, it’s inherent issues, and how it impacted her. When I hear clinicians describe 10/10 as childbirth, that is in fact along the lines of what the researchers had in mind when they went into a labor and delivery ward and burned laboring women’s hands to identify what “maximum pain” was. Yes, you read correctly. There is also research purporting the role of operant conditioning in chronic pain states. All of this leads me to question the utility of a 0-10 pain scale. And what does it tell us really? It doesn’t tell me what a patient can do, how they feel, how they manage, if they need a break, if they are fulfilling their goals, or if they are able to participate in work, recreation, or social activities. Commonly I hear patients give canned answers or try to find the rating they think the clinician wants to hear, or the rating that they think will allow them to continue treatment. The bottom line is, we can do better.

Here is what I do instead: I initiate the conversation of baseline versus flare-up on evaluation (more on that later), and pacing (more on that later too). During treatments I focus on activity tolerance. Often patients believe that they must toil away until they can’t function, which can incapacitate them afterwards. When this occurs, they are not being mindful of their activity tolerance. Instead of it being beneficial to “do more”, it actually leads to less activity overall. During an intervention I'll "check in" with my patient and ask "How are you feeling? How are you tolerating this? Can you keep going or do you need a break?" Utilizing pacing concepts I educate them that the point isn’t to work until a flare up occurs, but to “tune in” to how they feel and recognize when they need a break, before a flare up happens.

Patient’s struggle with their perceived value when you tell them to do less. Entrenched in our society are beliefs of value based upon work harder/do more/no pain no gain. This perpetuates unhelpful concepts of worthiness and worthlessness. I educate that doing less right now is temporary. A lower pain rating isn’t the objective. Being able to move without it leading to a flare up, is the goal. It typically takes a few sessions for patients to demonstrate understanding and begin implementing this. Early on I encourage patients to do less until they have a better handle on self management strategies to mitigate flare ups and a deeper understanding of their flare ups. I begin to build capacity once the patient is more tuned in to their tolerance, flare ups, and pacing. I may have several sessions with a patient where they do no physical activity whatsoever and instead focus solely on pacing, flare ups, self management, and graded exposure.

Here is how I document it:

Subjective: Patient reports that they can perform 45 minutes of activity. But when they do they are unable to do anything else the rest of the day.

Objective: tolerance and pacing: Patient was educated on being mindful of activity tolerance and taking breaks sooner. She was educated to trial taking breaks after 30 minutes of activity and when she feels able, return to activity. If she returns to activity, trial a second duration for slightly shorter than the first initially as she identifies what her current limits are.

Follow up sessions:

Subjective: Patient reports that she took breaks at 35 minutes initially and after a 30 minute break she was able to perform another 20 minutes of activity. She needed to stop the activity after that but did not experience a flare up.

Objective: tolerance and pacing: Patient was educated to continue current pacing and tolerance mindfulness. She was educated that she could trial returning to activity after second break and be attentive to her tolerance and duration before stopping the activity.

example of tolerance during physical intervention:

Objective: Throughout session patient was asked how they were tolerating the activity. Patient initially would respond with a pain rating and therapist would redirect patient and ask how they feel/if they need a break. Patient understood and implemented concept better after reeducating 3x. Rest breaks were taken as noted above. (document patients breaks within your note.)

Assessment: By the end of todays session patient demonstrated better implementation of tolerance concepts as she no longer required therapist guidance when asked how she feels/if she needs a break. She expressed understanding that she should use this concept during her daily activities and take breaks as necessary.

Subsequent subjectives statements may include patients observations about how well they feel they were able to use “tolerance” outside of the therapy session, how they feel it helped them, or what challenges they experienced with implementing it. Later assessments may document that patient self initiated need for breaks demonstrating competence in the concept.

Norman, A. (2018). Ask me about my uterus. New York: Nation Books.

Flor, H., Knost, B. and Birbaumer, N. (2002). The role of operant conditioning in chronic pain: an experimental investigation. Pain, 95(1), pp.111-118.

Korff, M. V., Ormel, J., Keefe, F. J., & Dworkin, S. F. (1992). Grading the severity of chronic pain. Pain,50(2), 133-149. doi:10.1016/0304-3959(92)90154-4

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