Are There any Objective Measures of Pain?

[fls]

This was the point I was trying to make regarding UY's anecdote. Would he have been happier to have been doped up to feel no pain and never learning the cause of the pain?

I can see the pain of labor and childbirth being a little bit different in that we know the source of the pain. I'm not sure why they frequently want to wait so long to give the woman an epidural.

There are (possibly) practical reasons for doing so. Labour with an epidural is longer than labour without and more often leads to c-section.

Linda

 

[fls]

But bearing in mind that the "pain-o-meter" isn't really measuring pain (which really is a subjective phenomenon) but rather some physiological measure (most likely neural activity in a certain location that correlates with self-reports of pain in many--but certainly not 100%-- of subjects studied), do you feel the same way?

A lie detector would make police work and the task of many courts more effective and efficient, but such a machine doesn't really exist. Instead we have a polygraph, which takes a bunch of physiological measures. . . .

Well, I was thinking of a true pain-o-meter - i.e. one that was really measuring pain. But even a pain-o-meter like UncaYimmy described, which was based on a collective evaluation, would be much less variable than using individual evaluations.

Linda

 

[JoeTheJuggler]

Well, I was thinking of a true pain-o-meter - i.e. one that was really measuring pain.

Which would have to be magic since pain is a subjective experience by definition.

But even a pain-o-meter like UncaYimmy described, which was based on a collective evaluation, would be much less variable than using individual evaluations.

But variable nonetheless. You couldn't ethically refuse to believe someone's self-report of pain based on a measure that can't possibly take into account individual variability.

I'm also very skeptical that you could find such a measure that would be more reliable than self-reporting in the first place.

I mentioned above a few reasons why: variability in human physiology wrt to brain wiring, brain plasticity upon injury, variability in the way the ARAS sets the internal "gain" on sensory input, variability depending on changeable states of arousal even within the same person--that is, if I'm distracted my pain is less than it is if I just like there thinking about how bad it hurts--and so on.

 

[JoeTheJuggler]

There are (possibly) practical reasons for doing so. Labour with an epidural is longer than labour without and more often leads to c-section.

So there could be practical reasons in this and other situations for delaying or withholding pain relieving drugs other than not believing the patient.

I think it's possible that many patients think their self-reported pain isn't believed when the reasons for not managing the pain more aggressively might be medically legit (and have nothing to do with providers not believing them). Unless the staff said something to UY like "I don't believe it hurts as bad as you say, and that's why I'm not going to give you anything stronger", I don't see how a patient in that position could know that staff isn't believing him.

It does argue, however, that someone might have done a poor job of communicating with him if they couldn't take the time to assure him that they're taking his complaint of pain seriously.

 

[Uncayimmy]

This was the point I was trying to make regarding UY's anecdote. Would he have been happier to have been doped up to feel no pain and never learning the cause of the pain?

Sounds to me like you have no experience with serious pain because your comments border on the ridiculous.

I've never encountered a painkiller that kept me from feeling pain except for when I was in the hospital. In those cases I got some sort of injection/drip (can't recall because each time I was either puking from the severe pain or so messed up I couldn't see straight) that brought immediate relief, albeit it temporary. Otherwise, we're talking a dulling of the pain at best. People on painkillers are not pain-free.

As for your comments about finding the source, that's just an incredibly stupid thing to say. Why do you think I was seeing the doctor in the first place? And why did I see a neurologist after that? And then get an MRI? And then back to the neurologist? Do you really think people want to go through life with chronic pain and pay for and take painkillers on a daily basis?

If the doctor has a concern about follow-up, that's already handled. Did you think they hand out narcotic prescriptions with a year of refills or something?

I can see the pain of labor and childbirth being a little bit different in that we know the source of the pain. I'm not sure why they frequently want to wait so long to give the woman an epidural.

Why should it be any different?

Is it because, you know, there's some sort of, I dunno, objective element involved? It's not like know for sure if the woman needs analgesic. We just know with a degree of confidence that a particular indicator for pain (childbirth) is consistently correlated with subject reports of severe pain.

Remember, it's not childbirth that's the pain. The pain is purely the subjective experience in the woman's consciousness. When we hear her screaming in agony and watch her perineum tear, those things are not pain. At best we can just look at those things as possible indicators of pain, but it will never be as accurate as the subjective measure of pain given by the patient.

 

[Fnord]

I use "Patch Days," measuring the number of Salonpas patches I need to dull the pain.

0 patches = No pain or pain is easily ignored.
1 patch = I need just a little help ... I'll be fine.
2 patches = I'm gonna sit here until I feel better.
3 patches = I'm gonna lie down until I feel better.
4 patches = "Hello, Doc? Get the Demerol ready. I'm coming in..."
5 patches = SOMEBODY SHOOT ME! JUST *&^%$#@ SHOOT ME!!!

 

[Uncayimmy]

Really? Women are bombarded with the message that we are less than worthy if we fail to take on this challenge - from the overt to your more subtle message that somehow I wasn't up to facing a challenge.* Why wouldn't you expect the idea to be perpetuated in the hospital, especially since you also chose to convey this message by using the word "challenge" (twice).

I mistakenly assumed that hospital personnel were smarter than me in regards to my attitude towards pain. I guess not.

Did you say it to her just like that?

Actually, I pointed out the times she has seen me in severe pain. I asked her to think about whether she would have wanted me to take steps to avoid that pain if those steps had just few minor downsides.

*So that you don't think poorly of me (), I should mention that I delivered 3 children without any analgesia and a fourth with only some partial pain relief.

I caught the smilies, but I still want to say that I don't think poorly of anybody who wants to avoid pain. If you don't mind me asking, how bad was the pain? Can you compare to other pain you've felt? Do you think your subjective ratings of pain before and after your first child changed because your scale expanded?

 

[Uncayimmy]

Upon further reflection we can say in a sense that we already have some objective measure that correlates with pain (using Joe's definition that pain is the subjective experience only). That measure is the source of the pain. This could be a cut, a burn, something pressing on a nerve, a poison (scorpion sting) or any number of other things.

While there may not be an official table listing various injuries and the corresponding reports of subjective pain, we all feel comfortable saying that someone with a small cut on his heel is in less pain than a person with a large slice in the palm of the hand. Likewise we figure that a bee sting (absent a severe allergic reaction) is less painful than a sting by a bark scorpion or bite by a black widow spider. And a person getting stitches under local anesthetic feels a lot less pain than someone being treated for a similar injury with no local.

Without a doubt this objective source of pain is a useful tool in determining the degree of pain reported by a patient. You don't get morphine (or whatever they use these days) for a bee sting, and you don't get Tylenol for a broken arm. Furthermore, these objective sources are more reliable indicators than subjective reporting.

What I hope for and what Linda refers to as a Pain-o-Meter would be something that measures whatever it is that happens between the source of the pain and the conscious realization of pain. Scientists have tried to find something, but haven't yet. That's no reason to stop looking.

 

[whatthebutlersaw]

Since my line manager is specialized in pain studies, most of my training to become a stat programmer was conducted on pain studies. I am, however, not a clinician. I have only seen the numbers produced, read the protocols and written programs to turn the raw data into reports. So I don't pretend to understand what they are actually measuring. First they get a baseline reading, then they dose the different analgesics they are testing and retest. We check them with different sized brushes, needles, heat and cold.

From the baseline readings, I would conclude that people do indeed report their level of pain very differently. But I have no way of knowing if this is because they are _feeling_ more intense pain or if they are more averse to feeling pain.
I have had migraines most of my life - the level of pain after which I am no longer able to function is very high in my own estimate and I would have a hard time answering the surveys used on our pain patients because I am feeling very intense pain (and if asked would describe it as unbearable) _long_ before I am ready to state that the pain is so bad that I can no longer go to work or function. I know this may sound odd, but the point at which a migraine becomes so bad I would happily suck a gun rather than go on comes before the point where I don't get up and dress for work. I actually haven't missed a day of work/school due to the migraines. Does that mean that I feel less pain than someone who would? Probably not - I'd gladly die at that point. Or conversely, would they be sissier than me for staying home? Of course not - they have different (probably sounder) priorities than me.

I also require more pain killers than my size would have you believe before I get any relief. My current dentist is the first ever to get the anaesthesia right, so I just didn't bother with it before I found him. Yes it hurt. Now it doesn't. I love my dentist.

My childhood dentist didn't believe in anaesthezising children - it's tricky to get the dosage right and they are easy to hold down after all. I think the Victorians didn't think children felt pain like adults? Or is that a myth?

It's a complex question and despite having access to a lot of data surrounding it, I don't have a good answer. That is probably because I lack the skill to interpret the data though.

 

[Darat]

...snip....

I also require more pain killers than my size would have you believe before I get any relief. My current dentist is the first ever to get the anaesthesia right, so I just didn't bother with it before I found him. Yes it hurt. Now it doesn't. I love my dentist.

...snip....

Quick personalish question - are you a redhead?

 

[fls]

Which would have to be magic since pain is a subjective experience by definition.

Do you think that it's impossible for us to access subjective experiences?

But variable nonetheless. You couldn't ethically refuse to believe someone's self-report of pain based on a measure that can't possibly take into account individual variability.

I'm also very skeptical that you could find such a measure that would be more reliable than self-reporting in the first place.

What would you make of someone who self-reported that you should give them the job because they are very smart and the IQ test you gave them came back at 88?

I mentioned above a few reasons why: variability in human physiology wrt to brain wiring, brain plasticity upon injury, variability in the way the ARAS sets the internal "gain" on sensory input, variability depending on changeable states of arousal even within the same person--that is, if I'm distracted my pain is less than it is if I just like there thinking about how bad it hurts--and so on.

We already do this on a less formal basis. Even though all these issues come into play, our degree of concern as to the possibility of particular diagnoses reflects the degree of reported pain (i.e. this sort of abnormality is associated with this degree of pain), such that reports of pain that are too far off from what we expect rule-out particular possibilities. I'm not sure how doing this on a more controlled basis wouldn't make it better.

Linda

 

[fls]

I mistakenly assumed that hospital personnel were smarter than me in regards to my attitude towards pain. I guess not.

It's variable. Undertreating pain is an ongoing issue (although I think we're getting better at it).

I caught the smilies, but I still want to say that I don't think poorly of anybody who wants to avoid pain.

I realize that. I also don't think that someone who uses "he" when making a generic reference to doctors thinks that female doctors are rare. Your use of the word "challenge" does inadvertently give that impression, though, which wouldn't matter if women didn't already receive the message that 'good' mothers undergo 'natural' childbirth.

If you don't mind me asking, how bad was the pain?

Not the sort of "just shoot me" pain that whatthebutlersaw or Fnord mention - the sort of pain you can imagine as like pain you've already experienced but much worse. It's beyond that to a pain where you are incapable of following instructions, incapable of caring, you have no choice but to lose control.

Can you compare to other pain you've felt?

I've had a couple of weird episodes of pain which were similar in intensity to labour (these happened before I had any children). I don't know what they were. Other than that, I think I've had a fairly normal range of pain experiences (no broken bones except toes) except that I also have migraine headaches. Before I experienced otherwise, I'd say that the bad migraines were close to the worst pain imaginable (other than trying to imagine what torture feels like when I'm watching horror movies).

Do you think your subjective ratings of pain before and after your first child changed because your scale expanded?

Yeah. Now my scale ends at "would you be able to run out of a burning building?"

But I guess that would be a problem with standardizing an instrument. Self-reports will depend on your own experience plus your imagination.

Linda

 

[Uncayimmy]

I realize that. I also don't think that someone who uses "he" when making a generic reference to doctors thinks that female doctors are rare.

I find the use of "one" to be pretentious, but I sometimes do it. I find the use of "she" even more pretentious and rarely do it. I have no problems with using "they" and "their" because we used to have singular and plural forms of "you" and "your". We learned to get the meaning by context. However, in discussion forums some people get all pedantic about it because we haven't finished making the transition. In another 50 or 100 years it will be accepted practice - hjust ask your grandchild's English teacher, and they will tell you it's okay.

For the record, my primary care physician and current neurologist are both women. My dentist before I moved out west was a woman.

Yeah. Now my scale ends at "would you be able to run out of a burning building?"

That works.

But I guess that would be a problem with standardizing an instrument. Self-reports will depend on your own experience plus your imagination.

True. But my prediction is that on a scale of 1 to 10, I doubt we'd see a significant number of reports greater than +/-1 from the median. I kind of see the scale two ways. It's useful for comparisons to the norm as well as comparisons to before and after within the individual.

 

[R.Mackey]

Edited by Cuddles: 

Edited reference to removed post.

Sci-fi has given us a few quantitative measures of pain. One of the funniest measures it in (what else) Hurtz.

Back in the land of reality, apart from active brain scanning, I don't have any idea how to do it.