How to Recognize and Assess Pain

Pain is a distressing sensation commonly experienced with injuries, infections, and disease. Pain is often difficult to assess, particularly in terms of its nature and intensity, because it is largely based on an individual's perception of how "bad" the pain is.

There are several tools, however, that can help your healthcare provider better understand how you are experiencing pain as an individual. This includes pain scales and charts commonly used after major surgery or when managing chronic pain conditions.

Whether your pain is acute (sudden and severe) or chronic (persistent or recurrent), communicating your experience of pain can help your healthcare provider prescribe the best possible treatments for your type and level of pain.

This article describes the various tools used to assess pain in children and adults.

Understanding What Pain Is

Pain is an unpleasant sensation telling you something in your body is wrong. When a part of the body is injured or affected by disease, nerve signals are sent to and from the brain creating sensations that we perceive as pain.

Pain can be categorized in different ways:

• Acute pain: Sudden onset of pain lasting less than 30 days
• Subacute pain: Pain that lasts from one to six months
• Chronic pain: Persistent or recurring pain lasting more than six months
• Localized pain; Pain felt in a specific part of the body
• Generalized pain; Pain felt all over (often described as "aching")
• Diffuse pain: Pain felt all over but hard to attribute to any single part of the body
• Somatic pain: Specific pain coming from an injury of tissues or a body structure
• Visceral pain: Vague pain originating in the abdomen, chest, intestines, or pelvis
  
• Neuropathic pain: Pain caused by a damaged or compressed ("pinched") nerve
• Radicular pain: Nerve pain originating in one part of the body that is "referred" to another
• Musculoskeletal pain: Pain related to muscles, bones, and supporting tissues
• Epigastric pain: Upper abdominal pain
• Pleuritic pain: Pain arising in the chest wall
• Cephalalgia: Headache or migraine pain
  
• Allodynia: Pain caused by things that usually do not cause pain
• Hyperalgesia: An exaggerated response to pain stimuli
• Nociceptive pain: Pain caused by damaged tissue
• Nociplastic pain: Pain caused by injury or dysfunction of the central nervous system
• Psychogenic pain: Physical pain that occurs during emotional or mental pain
  
• Breakthrough pain: Pain once controlled by treatment that spontaneously re-emerges
  
• Phantom pain: Pain felt on a part of the body that has been amputated

Many of these types of pain can co-occur or overlap, such as generalized hyperalgesia or chronic radicular pain.

Communicating Pain Intensity and Sensations

What is harder to describe is the intensity of pain because pain is ultimately an individual experience. Some refer to this in terms of a person's "pain threshold," or how much pain they can experience before it is considered "bad" or "intolerable." As such, some people are said to have "high pain thresholds" or "low pain thresholds."

But even this definition falls short given that a "threshold" suggests a consistent point by which pain is always felt in an individual. But, the fact is that different factors can continually alter one's perception of pain, not least of which is a person's emotions.

Wherein people tend to feel less pain when they are happy or frightened (due to the release of "feel-good" hormones like endorphins or stress hormones like cortisol), they tend to feel pain more when they are depressed, frustrated, anxious, or angry. This is because negative emotions can make your perceptions about everything worse, including pain.

Equally hard to describe are pain sensations that people will describe using adjectives like:

• Sharp
• Stabbing
• Shooting
• Burning
• Searing
• Dull
• Deep
• Aching
• Tingling
• Prickly
• Blinding
• Gnawing
• Cramping
• Throbbing
  

As generalized as these descriptions may seem, they provide important clues as to the type and intensity of pain you are experiencing.

4 Pain Scales and How They Are Used

The first step in assessing pain is to find out how bad it is. This is done with tools called "pain scales" that subjectively evaluate how a person experiences pain in different ways.

Self-reporting is the most reliable measure of pain. Even if a person "catastrophizes" and their response to pain is exaggerated, it is still how they genuinely experience pain. Without a self-report, a healthcare provider may underestimate the severity of pain and treat people based on how they "should" be feeling.

These are four pain scales commonly used in nursing and chronic pain management:

• Numeric Pain Rating Scale
• Wong-Baker FACES Pain Scale
• FLACC Scale
• Verbal Rating Scale

These pain scales are useful as they take less than a minute to administer. The scales are relatively easy for people to understand and don't require much, if any, translation when used for the appropriate patient.

Numeric Pain Rating Scale

The Numeric Pain Rating Scale (NPRS-11), also known as the Numerical Pain Rating Scale, is an 11-point scale for self-reporting your pain experience. It is used to describe the intensity of pain (referred to as unidimensional pain) in adults and children over 6 years of age.

The patient selects a number between 0 and 11, with 0 meaning no pain to 10 meaning the worst possible pain.

The NPRS-11 is often categorized as follows:

• 0 = No pain
• 1-3 = Mild pain
• 4-6 = Moderate pain
• 7-10 = Severe pain

Although the NPRS-11 is thought to be one of the more accurate ways to assess pain intensity, it has limitations as the categories do not necessarily reflect the patient's true meaning. Even so, the NPRS-11 may be useful in assessing the effectiveness of pain management therapies over time.

Wong-Baker FACES Pain Scale

The Wong-Baker FACES Pain Rating Scale is used to subjectively assess an individual's experience of pain based on a series of six faces ranging from a happy face (indicating "no pain") to a crying face (indicating "hurts worst").

Signs and symptoms that a person may exhibit if they are in pain:

• Facial grimacing or a frown
• Writhing or constant shifting in bed
• Moaning, groaning, or whimpering
• Restlessness and agitation
• Appearing uneasy and tense, perhaps drawing their legs up or kicking
• Guarding the area of pain or withdrawing from touch to that area

With the Wong-Baker Pain Scale, each facial expression observed by the healthcare provider is assigned a numeric value from 0 to 5 along with an interpretation:

• 0 = No pain
• 1 = Hurts a little bit
• 2 = Hurts more
• 3 = Hurts even more
• 4 = Hurts a whole lot
• 5 = Hurts worst

The Wong-Baker Pain Scale is useful for children over 3 years of age and people with intellectual disabilities. It may be less helpful in other groups as the interpretations are very generalized.

FLACC Scale

The FLACC Pain Scale is used for children over 2 months and others who are nonverbal. Rather than using a self-report, the FLACC Scale is assessed through observation of a child's face, legs, activity, crying, and consolability. The child is assessed for two to five minutes if awake and five minutes or more if asleep.

The FLACC Scale ranges from 0 to 2, the value of which is assigned to each of the five domains.

The scores are then added up and interpreted as follows:

• 0 = Relaxed and comfortable
• 1-3 = Mild discomfort
• 4-6 = Moderate pain
• 7-10 = Severe discomfort/pain

The FLACC Scale is considered a valuable tool for children with mild to severe cognitive impairments, developmental delays, or cerebral palsy.

Despite its benefit in assessing procedural pain in children (such as caused by surgery or a medical procedure), it is unclear how useful FLACC is for assessing non-procedural pain.

Verbal Rating Scale

The Verbal Rating Scale (VRS), also known as the Verbal Descriptor Scale, is a self-report consisting of statements designed to describe pain intensity and duration.

The VRS is assessed on a scale of 0 to 4 using different adjectives to describe extremes in pain. It is intended for adults and children 10 years and over who have a grasp of the terminology.

Based on a characteristic of pain, such as pain intensity or duration, different descriptions are ascribed to each value. Examples include:

The VRS aims to characterize the nature of pain. There are many variations of VRS, some with different questions and others with scales ranging from 0 to 10 or 0 to 15.

The VRS may be less useful in young children, people with language barriers, or intellectually disabled individuals who may underestimate or overestimate their pain experiences.

Role of Palliation and Provocation

Palliation and provocation are important tools used to assess pain. First, a healthcare provider will want to know what makes your pain better (or palliates it). Then, they will want to determine what makes the pain worse (or provokes it).

The purpose of palliation is to not only determine what eases pain but also how much or little palliation is needed. This may include things like pain medications, changing positions, or lying only on one side of the body.

Palliation is especially important when prescribing drugs. The goal of pain medications is to prescribe the lowest possible dose of the safest drug to achieve sustained control. Overtreating pain exposes a person to a greater risk of side effects and, with opioid drugs especially, a greater risk of addiction.

In contrast, provocation aims to find out where the pain is and what causes it to intensify. It could be caused by lying on a particular side. chewing solid food, or applying pressure to the hip while standing.

During a physical exam, the healthcare provider will often manipulate a limb to see if pain is provoked. These insights can help narrow the possible causes of pain and or direct the appropriate physical therapy plan.

Communicating With Your Doctor

One of the most important things you can do for the person you are caring for is to keep an accurate record of their pain and their pain treatments. Once you assess their pain, record the severity and location, as well as any medications or treatments that you give them.

Take note of whether the medications or treatments were effective. Also, write down anything they may have told you about what makes it feel better or worse. This is a great way to team up with your healthcare professionals to provide the best palliative care possible.

Your pain log doesn't need to be detailed, but a few components will help your healthcare providers better assess both the location and severity of pain, as well as treatments that are or are not effective.

The table below is an example of a pain log for someone who has abdominal pain:

Summary

Assessing your pain accurately can help ensure you get the best treatment, neither undertreating the pain (and causing undue suffering) nor overtreating the pain (and causing avoidable side effects).

There are different tools your healthcare provider can use to characterize the nature of your pain, including pain scales and physical exams. You can help by recording your pain experience in a pain journal, including as much detail as possible.