Pain Tolerability Question vs Numeric Rating Scale

Pain Tolerability Question vs Numeric Rating Scale for Assessment of Self-reported Chronic Pain – Research Letter, Anesthesiology – April 20, 2020

This study shows that most people find high pain levels less “tolerable” (and more disabling). and this suggests that asking about the “tolerability” (extent of the disability) could be a more useful method of rating pain in general.

Introduction

The exclusive focus of the numeric rating scale (NRS) on pain intensity reduces the experience of chronic pain to a single dimension. This drawback minimizes the complex effects of chronic pain on patients’ lives and the trade-offs that are often involved in analgesic decision-making.   

We hypothesized that the incorporation of a standardized pain tolerability question (PTQ) (ie, “is your pain tolerable?”) would efficiently augment the information gleaned from the NRS and help to align patients’ expectations with realistic treatment goals.

Methods

Participants were recruited electronically after a primary care encounter at 1 of 157 participating primary practices from December 2016 to March 2017.

Patients were asked the PTQ “is your pain tolerable?” (yes, no, or not in pain) and asked to rate average pain intensity during the past 24 hours, with 0 indicating no pain and 10 indicating the worst pain imaginable.

To assess construct validity of the PTQ, responses to the question “is your pain tolerable?” were compared with responses on the NRS scale using logistic regression. 

Results

In total, 1384 patients were invited to participate in the survey including the NRS and PTQ; 663 patients (47.9%) responded.

Of those, 124 reported a 0 on the NRS or responded not in pain to the PTQ and were excluded. Two additional participants failed to complete the NRS, leaving a final analytic sample of 537 patients, with a median (interquartile range) age of 62.2 (54.0-71.0) years and 206 (38.4%) men (Table).

Of these, 202 patients (37.8%) had more than 1 chronic pain diagnosis; the leading diagnosis was musculoskeletal pain (eg, osteoarthritis or soft-tissue disorder), with 295 patients (54.9%).

A pain rating of intolerable was associated with higher NRS scores (odds ratio per 1-point increase on NRS, 1.1; 95% CI, 1.02-1.2; P = .01) (Figure).

  • In the moderate range of the NRS (ie, 4-6), 40 of 211 patients (19.0%) characterized their pain as intolerable, whereas
  • in the severe range of the NRS (ie, 7-10), 72 of 137 patients (52.6%) considered it intolerable.

Discussion

The overarching goal of chronic pain treatment is to make pain tolerable for the patient rather than to attain a targeted numeric rating.

Our findings confirmed the intuitive assumption that most patients with low pain intensity (ie, NRS score, 1-3) find their pain tolerable.

In contrast, the tolerability of pain rated between 4 and 6 varies substantially among patients. In this middle range, if a patient describes pain as tolerable, this might decrease the clinician’s inclination to initiate higher-risk treatments.

A substantial subgroup of patients with severe pain reported their symptoms as tolerable.

I find this baffling: when I have “severe” pain, I’m a miserable whimpering ruin huddling on the couch, close to incapacitated. I just can’t imagine anyone suggesting that such a state would be tolerable in the long run.

Discordance between tolerability and pain intensity may be an opening for a clinician to explore mood, sleep disruption, or the curtailing of activities to control pain.

Asking patients with chronic pain about pain tolerability directly addresses the main limitation of the NRS, which asks patients to rate a complex, highly subjective experience on a unidimensional intensity scale.

A limitation of this study is that patients could have had flares of chronic pain or superimposed acute pain episodes at the time of assessment.

Research related to the associations of using the PTQ with patient satisfaction regarding communication, treatment goal setting, and treatment effects could further characterize the value of the PTQ

I had meant to include the above study in my post on the Sheehan Disability Scale, which was based on this study but accidentally posted it before it was finished.

Below is a copy of that post and the rating scale:

I recently found a rating scale normally used for psychiatric disorders that rates a symptom’s interference in three large realms of life: Work/School, Social, and Family/Home. The Sheehan Disability Scale takes any troubling symptom seriously.
I think rating how much a person’s life is affected by their pain gives much more information than ratings of how bad pain “feels”. 
To me, pain is a straight forward functional impairment. If I wasn’t always struggling against pain and the constant fatigue that comes with it, I would happily be far more active, more productive, more social, more creative… more functional in every way.
Pain is far more powerful than just a sensation of “hurt”; it’s the body’s primal alarm to do or die, and difficult to suppress by design. This is why it’s not feasible to just “deal with it” over the long haul.
Like a fire alarm that gets stuck, the relentless shrieking alarm of constant pain wears down both body and mind.

Sheehan Disability Scale

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