Severe pain – what constitutes severe pain and how do you measure it?

newborn babyPlus we list some of the most painful conditions.

Measuring pain and levels of pain is a problematic area, and this is reflected in the huge number of different ways that medical professionals attempt to measure pain.

A quick check of the Wikipedia entry for ‘pain scale’ shows no less than twenty-eight different pain scales, of which the better known include…

Faces Pain Scale
A so called ‘self reporting’ method based on a series of images of faces (which go from happy to looking very upset indeed), where the person is asked which face matches their pain. It was originally developed to help children over three describe their pain, but can be used with adults as well.

FLACC
Another pain index developed for young children who cannot describe their pain in words, where the child is observed to see how agitated they are by considering facial expression – ‘F’, movement of legs – ‘L’, general activity – ‘A’, whether or how hard they are crying – ‘C’, and whether they can be consoled – ‘C’.

VAS (Visual Analog Scale)
Another self reporting technique where the person with pain is asked to choose a rating of that pain from a series of descriptions, generally measured from 0 to 10 or 0 to 100, where 0 is ‘no pain at all’ and 10 or 100 is ‘worst imaginable pain’.

An example of the VAS used in research is the Vallbona study. Using Bioflex magnets to treat painful trigger points, the subject’s VAS scores decreased from an average of 9.6 to 4.4, while the placebo group reduced from 9.5 to only 8.4.

The difficulty from a medical practitioner’s point of view is that these scales, although helpful, do not account for the huge variety of levels of tolerance of pain in the population, and people’s individual perceptions of which level of pain they are experiencing.

More recently, medical researchers have preferred more functional pain scores such as the Western Ontario and McMaster Universities Arthritis Index (WOMAC). WOMAC is a self-administered questionnaire that considers pain during movement, stiffness and physical function.

Also there are differences between men and women when it comes to pain, with women feeling the same level of pain more acutely, according to Stanford University pain psychologist Beth Darnall, who explains that how we experience pain is very personal and very relative and that men experience pain at a lower intensity than women.

Another issue is the type of pain, and there are many different types of pain, with the main distinction being between short term ‘acute’ pain, such as touching a hot plate, and longer term ‘chronic pain’. Other types of pain that are recognised as specific types include referred pain, where pain is felt in another part of the body to the affected area, phantom pain, which is where pain is felt in a limb that has been amputated and emotional pain, also recognised as a type of pain.

A team of neuroscience researchers from four universities in the US conducted a study in 2013 to determine if there could be an objective measure of pain levels by conducting fMRI (functional Magnetic Image Resonance) scans of 114 participants as they were subjected to various levels of heat-based pain.

The outcome was that they were able to identify pain ‘signatures’ which allowed pain to be compared accurately across different people with an accuracy of over 95%. Although this was a breakthrough in pain measurement, from a practical perspective (at least until such time as fMRI scanners are in every clinic and doctor’s surgery) the current pain measurement mechanisms, flawed though they are, will have to do.

Some of the most painful conditions

headacheA (very subjective) review of various online media sources comparing different causes of pain and where they rank on the severity scale shows a strong agreement on six causes of severe pain.

These were…

 

 

Trigeminal Neuralgia
Sometimes also referred to as Fothergill’s disease, this is caused by inflammation of the trigeminal nerve in the head. People experiencing the condition describe it as being like having lightning striking you in the face. Conventional pain medications often do not work and it is described as the most painful condition in the world. Around one in every 15,000-20,000 people are affected (clinics such as Lifestyle Therapies have used magnets to develop a novel treatment for trigeminal neuralgia)

Cluster headaches
A cluster headache tends to develop on one side of the head, often around the eyes, and can last for three hours or longer. They tend to affect men more than women, with some people comparing the pain to burns and pain during childbirth.

Burns
It is not just the pain of the initial burn, but the continuing pain as the body recovers from burns and the necessary treatment – replacement of dressings etc – that is so intensely painful. Generally very serious (fourth degree) burns are not as painful as less serious burns, due to damaged or destroyed nerve tissue not transmitting the pain signals with serious burns.

Complex Regional Pain Syndrome
Often simply referred to as CRPS, this type of pain can come on after a heart attack or stroke, or after injury or surgery. The pain of CPRS can be a burning or throbbing sensation or muscle spasms or sensitivity, and is often far worse than the pain of the initial condition or injury.

Kidney stones
The jury is still out as to whether the pain of kidney stones is worse than the pain of childbirth. Either way kidney stones can be acutely painful. Kidney stones are hard deposits made up of minerals that can get lodged in the kidneys. Sometimes they can be very small and be passed in the urine, and in other cases surgery is required.

Childbirth
This is the obvious one and there’s no doubt it is a painful process. The most painful part is the labour phase before the actual birth.

There are many other things that can cause excruciating pain, and honourable mentions go to tetanus, broken bones and ruptured tendons (the most painful being the femur in the leg and the achilles tendon), peritonitis, tooth abscesses and gout.

Other very painful conditions mentioned included…

  • Acute pancreatitis
  • Appendicitis
  • Arthritis
  • Bullet ant sting
  • Dercums disease
  • Emotional pain
  • Endometriosis
  • Fibromyalgia
  • Frozen shoulder
  • Gonadal torsion
  • Heart attack
  • Irukanji jellyfish sting
  • Migraine
  • Post surgical pain
  • Penile fracture
  • Pudendal neuralgia
  • Road rash
  • Sciatica
  • Shingles
  • Sickle cell disease
  • Slipped disc
  • Spinal/postdural puncture headache
  • Stomach ulcer
  • Stonefish sting

 

References

https://en.wikipedia.org/wiki/Pain_scale
https://en.wikipedia.org/wiki/Visual_analogue_scale
https://en.m.wikipedia.org/wiki/FLACC_scale
https://www.physio-pedia.com/WOMAC_Osteoarthritis_Index
https://www.macmillan.org.uk/information-and-support/coping/side-effects-and-symptoms/pain/different-types-pain-describe.html
https://io9.gizmodo.com/scientists-succeed-in-objectively-measuring-pain-472456061?IR=T
https://www.nejm.org/doi/full/10.1056/NEJMoa1204471
http://digg.com/video/most-painful-human-experiences
https://list25.com/25-worst-pains-humans-can-experience/4/
https://www.menshealth.com/trending-news/a19533392/6-pains-worse-than-childbirth/
https://modalitypartnership.nhs.uk/self-help/livewell/topics/pain/20-painful-conditions

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