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The Comparative Pain Scale

By Jack Harich - July 14, 2002

A bit of web research shows there is no definitive pain scale in use in the medical industry. The best I could find was an article on Elder Pain: Assessment of Intensity (this link is now broken). This listed several scales, none of which had uniform, objective descriptions of pain per level. For example, the Verbal Description Scale (VDS) uses these words to describe pain levels:
0 = No pain
1 = Mild pain
2 = Discomforting
3 = Distressing
4 = Intense
5 = Excruciating
Or as Joan Barron wrote on July 14, 2002:

"The book Mayo Clinic Chronic Pain is a very useful book......I refer to it often. Health care professionals typically measure pain on a scale of 0-10 , with 0 being no pain and 10 being the worst pain imaginable. [The scale they use is:]

0-1 No pain
2-3 Mild pain
4-5 Discomforting - moderate pain
6-7 Distressing - severe pain
8-9 Intense - very severe pain
10 Unbearable pain"

But what is mild to one person may be terrible to another. Or if you are feeling tired one day and not the next, pain may feel worse when tired, due to the very subjective nature of the descriptive words. One complaint about this scale is "Patients tend to use the middle words and thus distort the assessment."

The McGill Pain Questionnaire is widely used, but is apparently copyrighted and used only under purchase and contract, and is hence unavailable to publish here, with at least one exception. It seems to consist of trying to measure a pain index from several dimensions. The chief one appears to use a choice of descriptive words from a list. Here's a description of the test and it's validity:

"The purpose of the McGill Pain Questionnaire is to provide a generic instrument for all painful health problems, to specify the qualities of pain, to determine the intensities implied by the The MPQ contains 78 pain words (MPQ short form: 15 pain words), grouped in 20 subclasses of 3 to 5 descriptive words. Within these subclasses the patient ranks the 3 to 5 pain words according to the implied pain intensity. The 20 subclasses are grouped in four sections, sensory, affective, evaluative and miscellaneous, which result in 4 scores. The 4 scores add up to a sum score, the so-called Pain Rating Index. This Pain Rating Index is the sum score primary outcome.

"In addition to the 78 pain words, the course over time is assessed with 9 words; the location of the pain is assessed with a drawing of a body with the words “external / internal” added. The face-to-face and the paper-and-pencil administration result in minor differences3. The administration takes 5-25 minutes (2-5 min for the short form)2,3,6. A manual was published in 1992.

"The psychometric properties are fair to good. The test-retest reliability for the 20 categories of pain descriptors calculated as Pearson correlation coefficients range from 0,29 to 0,83 with a median of 0,48. For the 4 composite subscales the Pearson correlation coefficients are: sensory subscale 0,76, affective subscale 0,78, evaluation subscale, a single category, 0,47. The coefficient for the sum score, the Total Pain Rating Index, is 0,832. The internal consistency is investigated thoroughly and found to be good. This is supported by Reading using a different methodology."

Thus we have developed our own pain scale. Use of it gives pain ratings that can more reliably be compared, both from patient to patient, and from day to day on the same patient. It is objective and repeatable because it compares your pain to a known level of pain or behavioral symptoms. The scale is logarithmic. Note that above level 4 you cannot adapt. Note that your pain level probably varies. The descriptive words describe pain intensity, not type of pain.

The two end of the scale, zero and ten, are the two possible extremes. I first described them, then worked up from zero, and when I got to about four I started working down from ten. Eventually the gap closed, fidgeting was done, and the result is hopefully a smooth logarithmic curve and an easy to use scale.

To use the scale, first determine if your pain is Minor, Moderate, or Severe. Then look at the levels within that group and select the one the comes closest to describing your level of pain.

Comparative Pain Scale
0
 No pain. Feeling perfectly normal.

Minor

Does not interfere with most activities. Able to adapt to pain psychologically and with medication or devices such as cushions.
1
Very Mild
Very light barely noticable pain, like a mosquito bite or a poison ivy itch. Most of the time you never think about the pain.
2
Discomforting
 Minor pain, like lightly pinching the fold of skin between the thumb and first finger with the other hand, using the fingernails. Note that people react differently to this self-test.
3
Tolerable
Very noticable pain, like an accidental cut, a blow to the nose causing a bloody nose, or a doctor giving you an injection. The pain is not so strong that you cannot get used to it. Eventually, most of the time you don't notice the pain. You have adapted to it.

Moderate

Interferes with many activities. Requires lifestyle changes but patient remains independent. Unable to adapt to pain.

4
Distressing
Strong, deep pain, like an average toothache, the initial pain from a bee sting, or minor trauma to part of the body, such as stubbing your toe real hard. So strong you notice the pain all the time and cannot completely adapt. This pain level can be simulated by pinching the fold of skin between the thumb and first finger with the other hand, using the fingernails, and squeezing real hard. Note how the similated pain is initially piercing but becomes dull after that.
3
Very
Distressing
Strong, deep, piercing pain, such as a sprained ankle when you stand on it wrong, or mild back pain. Not only do you notice the pain all the time, you are now so preoccupied with managing it that you normal lifestyle is curtailed. Temporary personality disorders are frequent.
6
Intense
Strong, deep, piercing pain so strong it seems to partially dominate your senses, causing you to think somewhat unclearly. At this point you begin to have trouble holding a job or maintaining normal social relationships. Comparable to a bad non-migriane headache combined with several bee stings, or a bad back pain.

Severe

Unable to engage in normal activities. Patient is disabled and unable to function independently.
7
Very
Intense

Same as 6 except the pain completely dominates your senses, causing you to think unclearly about half the time. At this point you are effectively disabled and frequently cannot live alone. Comparable to an average migraine headache.
8
Utterly
Horrible
 Pain so intense you can no longer think clearly at all, and have often undergone severe personality change if the pain has been present for a long time. Suicide is frequently contemplated and sometimes tried. Comparable to childbirth or a real bad migraine headache.
9
Excruciating
Unbearable
Pain so intense you cannot tolerate it and demand pain killers or surgery, no matter what the side effects or risk. If this doesn't work, suicide is frequent since there is no more joy in life whatsoever. Comparable to throat cancer.
10
Unimaginable
Unspeakable
 Pain so intense you will go unconscious shortly. Most people have never experienced this level of pain. Those who have suffered a severe accident, such as a crushed hand, and lost consciousness as a result of the pain and not blood loss, have experienced level 10.

Pain is inherently subjective. This was noted by Henry Knowles Beecher (1904 - 1976), an anesthesiologist. Here's an interesting extract from a writeup on his findings:
"Serving as an Army medical consultant on the Anzio beachhead, [Beecher] observed that soldiers with serious wounds complained of pain much less than did his postoperative patients at Massachusetts General Hospital. Beecher hypothesized that the soldier's pain was alleviated by his survival of combat and the knowledge that he could now spend weeks or months in safety and relative comfort while he recovered. The hospital patient, however, had been removed from his home environment and now faced an extended period of illness and the fear of possible complications. Beecher argued that "the reaction component" made pain such a complex and individualized phenomenon that it could only be studied effectively in the clinical setting. Patients with real pain would not exhibit the same physiologic manifestations or the same responses to analgesics as experimental subjects, who knew that they were in no serious danger and that the pain would soon cease."
If the source of pain cannot be eliminated or reduced, pain therapy is your only recourse. Here's a good summary of the state of Pain Therapy Today:
"Since 1973, the multidisciplinary pain clinic has come into its own. Many clinics now offer a variety of therapeutic approaches to effective pain management, including physical therapy, acupuncture, TENS (transcutaneous electronic nerve stimulation), hypnosis, and behavioral modification based on the methods pioneered by Bonica's colleague, Wilbert Fordyce. However, not all patients have access to good pain clinics and, in the US, many pain therapies are not covered by insurance.

Richard Sternbach, of the Pain Treatment Center at Scripps Clinic and Research Foundation in La Jolla, offered 7 steps on how to live despite pain in his 1977 pamphlet (How Can I Learn to Live With Pain When It Hurts So Much?, revised in 1983):

1. Accept the fact of your pain.

2. Set specific goals of work, hobbies and social acitivities towards which you will work.

3. Let yourself get angry at your pain if it seems to be getting the best of you.

4. Pace your activities. Get in shape, and keep fit. Learn to relax, and practice it.

5. Time your medications, then taper off them.

6. Have family and friends support only your healthy behavior, not your invalidism.

7. Be open and reasonable with your doctor."