Two-Part Chronic Pain Scale
Part 1 Functional Impairment
On a scale of 0 to 10 how functionally impaired are you by pain right now?
0 - Not at all
1 - Able to ignore it
2 - Mildly distracted
3 - Distracted
4 - Making mistakes
5 - Can't work
6 - Lying down resting
7 - Crying and/or moaning
8 - Can't move
9 - Needs ambulance
10 - Unconscious or needs sedation
Part 2 Baseline
What is your pain the past month on a low pain day where your pain is not functionally impairing you?
0 - No pain
1 - Could be an itch
2 - Small cut
3 - Tylenol will fix it
4 - Concerning
5 - Tylenol did not fix it
6 - Attacked by bees!
7 - Tylenol is useless
8 - Wants sedation
9 - Mauled by ninja
10 - Worst pain imaginable
Combined score: Add Part 1 and Part 2.
----
How It Works:
People with chronic pain have a higher pain tolerance than people without chronic pain. Many pain scales attempt to capture by shifting chronic pain scales to higher numbers say 1-15 with descriptions explaining that an average pain day would be 5-7. The problem is some people have more or less chronic pain than others. Therefore this scale attempts to capture each person's individual pain tolerance and adjust their individual functional scale accordingly. The addition works exactly the same as shifting a scale to go up to a higher number.
----
Benefits
Functional score is easily verifiable with a person's behavior
Clearly explains how the final number came to be and how much chronic pain tolerance someone has…
10 is still the worst pain imaginable (to a healthy person) but scale functions beyond 10
Chronic pain baseline explains why someone may be functional at high pain levels
For non-chronic pain patients just use pt 1 with pt 2 set to 0
---
Downsides
Is an extra question to ask...
Relies on patients having a decently stable baseline of chronic pain
Numbers above 10 may be slightly confusing at first
Some chronic pain patients may not have low pain days where they are not functionally impaired and have to guess a number
Emotional distress may make assessing functional impairment difficult
---
Personal Example: Migraine
If this scale had been given to me when I had my most recent migraine I would have answered...
6 for functional impairment
And
4 for baseline low pain day
For a combined pain rating of 10
This seems accurate as the first time I had one of these migraines before I was accustomed to chronic pain I rated it a 9.5 on the standard pain scale and was in the hospital getting IV medication and promptly passing out as soon as the sedatives kicked in.
---
Example Explained:
The score of 9.5 vs 10 is roughly equal between when I was a chronic pain patient and when I was not. However, the breakdown clearly explains why one day I was simply lying in my dark room waiting for it to pass and another I was calling an ambulance. The painfulness of the event didn't change but my pain tolerance and behavior has due to chronic illness.
---
A Reminder
Please note that this scale explains why chronic pain patients may be in ER still totally functional (under 5) but still be at a 10. If they have very high chronic pain levels they may even be over a 10 when their baseline is added into account.
---
/10 vs /20
I believe this scale should still be written as /10 as 10 on this scale still represent the worst pain imaginable. It is already fairly well understood that the worst pain imaginable is not as bad as many pain events. People simply cannot imagine the worst pain possible. So you can either say x/10 where 10 is the worst pain imaginable or x/20 where 20 is the worst pain possible. Note that the worst pain possible occurs when a person with extremely high pain tolerance is in extreme pain to the point of passing out. This is the worst pain possible because most people would pass out long before this point.
---
Scale Post Part 2 - Chronic Pain
Unlike severity, I do believe there are some good scales out there for pain particularly when it comes to descriptions. However, there is one part of chronic pain that I feel is never properly captured by scales and that is what this scale seeks to address:
How functionally impaired you are by pain is not a direct function of how bad the pain is.
Chronic pain creates pain tolerance and that tolerance is different for everyone.
This scale addresses the issue of functional impairment and pain tolerance by separating them into two individual scales. It works like this…
Patients with low pain tolerance will have a high functional impairment.
Patients with high pain tolerance will have a lower functional impairment.
The overall amount of pain can be calculated by adding up pain tolerance and functional impairment.
Separating numbers like this also avoids the awkward "Well, my pain is a 7 but it's normally a 6 so 7 is normalish for me." By including pain tolerance as part of the scale that 7 would be broken up into a low pain day reference say 5 and a level of functional impairment say 2.
By breaking up the numbers we can also have meaningful numbers higher than 10. This happens because when someones pain tolerance goes up the range of pain they can experience before passing out goes up as well. The amount of pain necessary to make someone whose everyday pain is a 7 cry is going to be a lot higher than someone whose everyday pain is a 3. Passing out is as functionally impaired as possible. But for someone whose baseline is say 5 that total pain range will go to 15 before they would pass out.
Breaking up numbers also means that people's functional presentations should line up with their reported pain due to the adjustment being separate.
Finally, this scale improves on others that acknowledge numbers above 10 by being more individualized. Rather than assuming chronic pain goes to one number for everyone the scale acknowledges that even low chronic pain has an adjustment on functional pain levels and that there can be exceptionally high chronic pain beyond what most people experience.
What do you think? Suggestions?
