Dynamic Chiropractic Canada – October 1, 2014, Vol. 07, Issue 10

Don't Turn a 2 Into a 10

By K. Jeffrey Miller, DC, MBA

The Wong-Baker FACES Pain Rating Scale1 is so useful because it can be used by almost anyone. Patients can use the numbers associated with the faces depicted on the scale or select the face that demonstrates their current level of pain from 0-10. Use of the scale is especially helpful with young patients or if a language barrier exists. Another useful aspect of the scale is when the patient's mental status in impaired either through chemicals (drug or alcohol) or due to mental illness.

Use of this and other numeric pain scales has increased tremendously in the past decade. In fact, their use has increased to the point that Medicare mandates use2 and pain assessment is becoming known as the new vital sign.3

Minimizing Rating Confusion

The commonality of pain scales means everyone practicing is quickly indoctrinated in their use. However, during indoctrination it becomes evident that some patients don't always understand the scales, always use the lowest possible number or always use the highest possible number. In order to clarify the use of a 0 through 10 scale, I provide patients with this explanation prior to asking them to rate their pain:

"I am going to ask you to rate your pain on a scale of 0 through 10. A 0 means you have no pain; 1 means you have noticed pain, but you would not do anything about it, like take an aspirin of call a doctor; 10 means you cannot drive, work, go to school, and work around the house or exercise. Now, on a scale of 0 to 10, what is your level of pain?"

These instructions usually result in a more accurate patient response, as points of reference are given prior to the rating. For patients who tend to rate pain at the low end of the scale, they may still do so, but at least you have tried to set the stage for an accurate assessment. (Keep in mind that some people have higher pain tolerances than others.)

The Issue of Pain Tolerance

Speaking of pain tolerance, patients frequently tell their doctor they have a high pain tolerance. In my experience, just because the patient makes this claim doesn't necessarily mean it's true. It isn't that the patient is lying; in most cases, they are trying to let you know they really do hurt. It is another way of telling you they would not be there if the pain was not truly bothering them. Patients in this situation are quick to report pain during examination in order to let the doctor know where the problem is located.

In reality, having a high pain tolerance means the patient does not experience pain. These patients always use the lower end of the pain scale or don't complain of pain. These patients could "take a punch" as though it were a drop of water hitting them.

There is a difference between having a high pain tolerance and saying, "I have had to tolerate a lot of pain." Patients who report a high pain tolerance fit the second description. People with a true pain tolerance don't report pain.

Patients who say they "have tolerated a lot of pain" actually tend to use the high end of the numeric pain scales. The instructions described above frustrate these patients. If a patient drove to the office after work, their pain definitely does not qualify as a 10. Good instructions usually bring the rating down to a more realistic 9.25 (smile).

The instructions frustrate hypochondriacs and attention seekers. They just cannot explain a 10 when they are working, driving, etc. My medical friends tell me their use of the instructions also frustrates patients who visit emergency rooms seeking pain medication.

Same Number, Different Pain

Another phenomenon encountered with the use of the numeric scales is the obvious discrepancies seen between different patients who use the same number. One patient may report a 9 after being carried in by his buddies. He can barely walk, is antalgic and writhing in pain. The next patient also reports a 9 after strolling in after work, says he is "dying" and needs a quick adjustment – so he can play in the golf tournament at the club this weekend.

The inconsistency here is due to different points of reference. You will see thousands of patients during practice. This gives you a point of reference based on thousands of patients and their pain ratings.

While patient perception has to be the number recorded, you have seen hundreds of 1's, 5's, 8's, 10's, etc. You know the difference and can categorize the patient's pain accordingly.

Establishing a Pain Range

For the patient, their point of reference is their own. If their current pain is the worst they have ever experienced, then the pain is a 10. If another episode occurs that is worse than the current one, they will rate it a 10 and hopefully realize the previous episode was a 7 or whatever the appropriate number would be. For the golfer, he was probably turning a 2 into a 10.

The instructions provided earlier are good for obtaining a current rating, but can also include the following to ask the patient about the lows and highs associated with their pain:

"On a scale of 0 to 10, what is your level of pain now? What number is your pain at its lowest? What number is your pain at its highest?"

A range is good to have. It can help determine the patient's pain level at different times of the day or week. It can also be correlated with activities to see what might be exacerbating the patient's pain.

The key for each of the situations here is points of reference. Having tolerated pain, having a high pain tolerance, being a hypochondriac, the patient's personal experience and the doctor's experience with thousands of patients all have unique points of reference. This leads to the realization that pain scales are subjective. It can be easy to turn a 2 into a 10, especially from the point of personal reference.

The Larger Picture

But isn't that human nature? Patients in health care systems are not the only ones distorting the scale of things. Everyone does it.

We leave our chiropractic college upset over an occurrence or policy and turn what is a 2 in the grand scheme of things into a personal 10. We become upset with our local, state and national chiropractic organizations and turn something that is a 2 for the profession as a whole into a personal 10. It's not that some things are not a 10, but too often, we become poor alumni and distant from our colleagues and profession for trivial reasons. I have done this and I am not alone.

We have all suffered personal pain. Yet we must maintain the perspective of the thousands in the rating of our pain and stick together. Many of the things we felt were 10's in the past were really 2's, particularly when compared to the things we face in the current health care crisis in America. Let's keep things in perspective, work together, develop a higher pain tolerance and stop turning 2's into 10's.


  1. The Wong-Baker FACES Pain Rating Scale. Wong and Baker FACES Foundation.
  2. Centers for Medicare and Medicaid Services (CMS), Physician Quality Reporting System, 2014.
  3. Smith J, Roberts R. Vital Signs for Nurses, an Introduction to Clinical Observations. Ames, IA: Wiley-Blackwell, 2011.

Click here for more information about K. Jeffrey Miller, DC, MBA.

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