Banner by Meghan Carlton

Tipping the (Pain) Scales

by Anna Cassidy

As a child, I suffered from chronic pain for months due to the inability of physicians to determine its cause. Every time I went into the doctor’s office, I was asked to evaluate my pain level. They usually pointed to a chart on the wall of six faces with expressions varying from smiling to crying, asking me to rate my pain on a scale of 1-10 in correspondence with the face best depicting how my pain made me feel emotion. Every time that I looked at that chart, I wondered if my pain qualified as a 10. My feet couldn’t touch anything; I had to prop my bedsheets above them because even that was too much weight. I had missed a month of school and was in two walking casts. That’s pretty bad pain by any standards, but was it a 10? I usually said an 8 because I didn’t want to seem too extreme. Regardless of the pain scale that I was given, I often resorted to my own descriptive words to describe my pain because I felt that this was the best way to communicate the nature of my suffering. My physicians would almost always comment on my creative description, but they still wanted me to pick a number or choose a descriptor. They wanted to standardize my pain, lumping it into a predetermined category. That was frustrating because it felt like I wasn’t being heard. They didn’t really care about how I felt. They just wanted to eliminate my pain by looking at a chart that told them how many drugs to prescribe or what measures to advise. The creators of these pain scales are researchers who have tried to standardize pain levels, but due to the personal nature of pain, this is extremely difficult. Hence, despite widespread use, these scales are inherently flawed.

Due to my frustrating experience with the use of pain scales in the treatment of chronic pain, I wanted to investigate ways to improve this less-than-ideal system. The six emotional faces ranging from happy to crying are part of what is called the Wong-Baker pain scale, one of the most common pain scales that is used today. This was the scale that I was most often asked to use in order to evaluate my own pain. These facial expressions are supposed to correspond to a number ranging from 0-10 that represents your pain level. The development of this pain scale began in 1981, when Connie Baker and Donna Wong noticed the failure of pain management in the pediatric burn unit at Hillcrest Medical Center in Tulsa, Oklahoma. They began working on a better way for children to communicate about their pain, thereby improving pain management. The development of the six faces was actually based on a conglomeration of drawings depicting pain levels through emotional states by the pediatric patients themselves. This explains the slogan ‘for children, by children’ that is a hallmark of the Wong-Baker scale. Despite its initial development for children, it has been deemed effective for all people above the age of two and is frequently used by physicians treating adult patients. I hated when my doctors tasked me with evaluating my pain using this scale, since it was deceptively challenging to choose a number and the corresponding emotion. While there is definitely an emotional aspect to pain, as children we learn to control our emotions. When I was suffering from chronic pain, I wasn’t spending my days crying. I was trying to push through so that I could dance and run and play with my sisters. So, when they asked me to choose a face that described my pain, I never felt like it was accurate. The face for a ten was crying, but I wasn’t crying, so did that mean that my pain wasn’t a ten? Baker and Wong actually observed that the children in the burn unit were not crying, yet they repeatedly chose to portray severe pain with a crying face. They weren’t spending all day crying, yet many still associated a crying face with severe pain. As a child, this association wasn’t as clear for me as it had been for them.  

I found the choice of qualifying words below the faces that range from ‘no hurt’ to ‘hurts worst’ on the Wong-Baker pain scale particularly interesting. Various studies, like Dr. Aude Paquet’s 2017 article published in Issues in Mental Health Nursing, have shown that past and present experiences of pain can influence a person’s perception of pain. The generic words that the pain scale uses, while seemingly accessible, can be too subjective. One person’s worst pain imaginable could be having their arm cut off by a blade, while someone else’s is stubbing their toe. Each person associates different experiences with a different amount of pain. We each calibrate our own personal pain scale, making them impossible to standardize. Due to the strong correlation between self-evaluation of pain and the treatment that a person actually receives, this becomes a huge concern. When I was receiving treatment, the pain that I was suffering from was some of the most excruciating pain that I experienced. However, I always imagined that it could be worse. I tended to use cancer as something to standardize my scale because I was familiar with its debilitating effects. Reminding myself that my pain could always be worse was actually a coping mechanism for me.

Other pain scales, like the Stanford Pain Scale and the Mankoski Pain Scale, use descriptive qualifying statements rather than qualifying words, which use increased details to describe and standardize pain levels. These systems are more attractive to me because there is more guidance available when choosing a pain level; however, they had not yet been created when I was undergoing treatment. Rather than shooting into the dark, the Stanford Pain Scale uses more advanced explanations of pain levels and employs figurative language to associate common ailments, like a mosquito bite versus a bee sting, with particular pain levels. This helps to eliminate personal bias, or “self-standardization.” The drawback of this type of scale is that it is not as accessible to children due to the lack of facial expressions. As a twelve-year-old I would have been able to read and understand it as it is still written in simple language, but it couldn’t be used with a five-year-old. However, the color association in this scale could be effective for adolescents. Pain rated 1-3 is green, 4-6 is yellow, and 7-10 is red. Since red usually means “bad,” this system is effective for a younger population but results in limited choices if the full details of the scale cannot be appreciated.

My research into pain scales has led me to a fascinating conclusion: that there are other options. Unfortunately, I was never presented with them. Scales like the Color Analog Scale take advantage of color association as the key way for identifying pain levels. The addition of emotional faces underneath the color scale aids in color standardization for pain association. This scale actually eliminates the 1-10 rating all together, which I always found to be the most difficult part. Another scale that eliminates the traditional 1-10 rating is the McGill Pain Scale, which uses descriptive words often associated with pain to determine pain level on a scale of 0-78. I can only imagine what it would have been like to have that many options and have the difficulty of picking one number that had the ability to change the direction of my treatment. Of all the scales that I found, the Defense and Veterans Pain Rating Scale that was released by the military in 2016 was by far my favorite since it employs a collection of these strategies to more effectively rate pain level. The scale uses associative faces, colors, the typical 1-10 scale and brief qualifying statements to help guide patients in choosing their pain level.

My research into the Wong-Baker Pain Scale revealed to me the vast number of pain scales that are available today. During the development of the Wong-Baker Pain Scale, children were asked to draw the emotional faces that they associated with certain levels of pain. While a pain scale can be used in an attempt to standardize pain, or as an attempt to aid patients in communicating their pain, personal expression through words and drawings may prove more effective in communicating some of the personal aspects of pain. With all of these options, I think that patients, rather than physicians, should choose the pain scale that they would like to use. I found that I was personally drawn to the Stanford Pain Scale due to the descriptive statements, but this is not effective or desirable for all patients. Pain is complex and an inability to effectively diagnose it can inhibit proper treatment. I wish that my doctors had listened to me when I told them that it felt like my foot was fighting a war and like it was being shot at repetitively by the enemy. No pain scale can describe my sharp, chronic pain as effectively as I could convey it. However, there are also people that struggle to communicate their pain and, in this case, the aid of a pain scale may be more desirable.

When faced with pain diagnosis and treatment, we must recognize that pain is unique to each person and challenges regarding pain standardization exist. If you are suffering from chronic pain and feel that the pain scale that your physician is using is not applicable to your case, do not be afraid to ask for an alternative scale or to use your own words to describe pain. The inability to diagnose and manage pain has real consequences and improvement of pain treatment will hopefully mitigate the pain management problems plaguing the healthcare field.