Pain Tolerability Question

[Taylor Blattenberger]

Here is a very short blurb from JAMA about taking the NPRS one step further. I know asking patients to rate their pain is sometimes a difficult conversation and per our discussion last night, it may not give us the entire picture. This almost seems too simple, but it can provide us with better information about pain experience.

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[helenrshep]

I actually think this is fantastic.

“Continually asking patients to rate their pain on a scale that is anchored by a pain-free state (i.e. 0) implies that being pain free is a readily attainable treatment goal, which may contribute to unrealistic expectations for complete relief.”

SUCH a good point. And while we as clinicians may be okay with a chronic pain patient getting down to a 3/10, they may be frustrated by not getting to a zero, vs if you reframe it to be a tolerability question, it’s a whole lot better for us to agree that “tolerable” is a win if it was previously “not tolerable.”

Another great point: the regular pain scale “reduces the experience of chronic pain to a single dimension” – so true and not a great way to try to capture the multi-faceted experience. I think a tolerability scale helps with communication too. As the authors pointed out, some patients that indicated a 6/10 pain then said it was tolerable, which may help us not move forward with higher risk treatment or referral when it’s not warranted.

[pbarrettcoleman]

I think this is a better way to phrase goals around pain. Having the pt report that their pain is tolerable is way more meaningful than me just writing some arbitrary goal of having <3/10 pain or whatever.

I don’t know how you guys use a pain scale, but for me it only consistently comes up for evals, PN, and discharges for documentation purposes. Since it is on our intake forms, I use it more for insight into the pt’s perception, relationship, and understanding to their pain. It’s just one blip of many on the radar to make a bigger picture. So many people fill it out wrong (“Worst pain is 5/10 but on Average it’s a 9/10” or “My average, best, and worst pain is a constant 5/10 but it goes up and down with these aggs or eases”) so I find it more useful to frame discussions around things that come up.

For instance, does the outcome measure match the pain listed? If someone is stating 9/10 pain, but the Qdash is <20%, then that is an opportunity to discuss the pt’s experience to get a better understanding of their interpretation.

How do you guys use NPRS? I would be terrified to try and and use that as assess/treat/reassess parameter since it is so subjective. I always try and tie my pain reduction interventions with active/passive/functional/palpation/MMT/SOMETHING to make it more concrete.

[awilson12]

I agree with you both that reframing questions for those with chronic pain about what people are thinking/how they are responding to our treatment is definitely beneficial. I like this way of going about it and am curious to see what the outcome is experimenting with implementing it with different patients.

I am on the same boat as you Barrett in that I don’t put a lot of stake in pain numbers but get them at evaluation and reassessment points (sometimes) for documentation purposes. I think I can do a better job of recognizing inconsistencies in pain report and outcome scores and using this to challenge beliefs rather than just moving on.

I think I only really ask pain numbers specifically with post-op patients to get a better idea of the degree of pain with exercises and if it is a “safe” pain versus something that needs to discontinued for the time being.

[Steven Lagasse]

A lot of interesting points here. I would subscribe to the idea of using the PTQ in place of or combined with the NPRS would work well when setting expectations. Also, I believe this tool could also be helpful during the evaluation when deciding whether to reproduce symptoms or focus solely on symptoms mitigation.

Barrett, I have used pain as an assess/treat/reassess parameter. However, I found this works best with only those patients who are health literate. I also attempt to qualify this with the statement that we’re looking for an evident or fairly dramatic change in subjective symptoms. Having the patient attempt to distinguish between whether their symptoms decreased from 4 to 3 (or vice-versa) is not all that helpful. Anyway, I would agree with you, far better to anchor parameters to an objective measure.

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