One of my most memorable migraines was on December 4th, 2015, when I freaked out and called the university nurse helpline at 2 a.m. for advice. The nurse asked me how I would rate my pain on a scale of 1 to 10, and I said, “This is the worst pain I’ve ever experienced.”
The nurse patiently said, “But what number would you give it?”
I said, “With a 10 being what? The worst pain I’ve ever experienced or the worst pain anyone has ever experienced?”
She replied, “It’s subjective- just do your best to give it a number from 1 to 10, with 0 being no pain and 10 being the worst pain you can imagine.”
I said, “Oh. Okay. An 8, I guess?”
The classic 1 to 10 Wong-Baker FACES Pain Scale is simple, and I can see how it could be valuable in a medical emergency. However, I think there are several problems with using it in a traditional clinical setting, especially for assessing chronic pain.
First of all, using a single scale oversimplifies a really complex physical and psychological experience. More specifically, it forces the patient to account for several factors at once: pain severity, duration, emotional distress, and disability. How can a patient compare the intense sensation of a broken arm to the perpetual but perhaps less intense sensation of fibromyalgia using just one number? At first it seems like the broken arm should be rated higher because it’s more severe, but as soon as you start to factor in the emotional distress, disability, and anxiety that an ongoing chronic pain condition can cause, the logic of this pain scale starts to crumble. A more accurate assessment of pain ought to have the patient rate the pain on several separate factors, including severity, duration, emotional distress, and disability.
Another problem with the FACES Pain Scale is that the patient doesn’t have any specific criteria for each number, 1 through 10. The scale labels the numbers with cartoon faces and vague descriptions: “No Hurt”, “Hurts Little Bit”, “Hurts Little More”, etcetera. There’s nothing scientific about a description like “Hurts Little More”. And how do the cartoon faces relate to my experience of pain? When I have a migraine for 12 hours I don’t go around grimacing the whole time. I usually smile and act like my normal self as much as possible.
Furthermore, there’s the problem of the elusive 10. The nurse on the helpline characterized a 10 on the FACES Pain Scale as the worst pain imaginable, but I’ve found that it’s nearly impossible to imagine a pain experience that I haven’t had. As a result, I think many patients tend to shy away from the number even in the most painful emergencies, while others will use it liberally. There’s no clear consensus on what a 10 means, which leaves the rest of the scale in just as much uncertainty.
What do you think about the FACES Pain Scale? I’d love to hear your take on it, especially if you are a doctor or chronic pain patient.
Also check out another wonderful blog post on this topic at the Dancing With Pain blog!
Image Credit: Wong-Baker Faces Foundation