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Evaluation of Pain

by Russell K. Portenoy, MD

Neither examinations nor tests can prove that a person is in pain. Consequently, doctors ask the person about the history and characteristics of pain. The person’s answers help them identify the cause and develop a treatment strategy. Questions can include the following:

  • Where is the pain? What is the pain like?

  • When did the pain start? Was there any injury?

  • How did the pain start? Did it begin suddenly or gradually?

  • Is the pain always present, or does it come and go?

  • Does it occur predictably after certain activities (such as meals or physical exertion) or in certain body positions? What else makes the pain worse?

  • What, if anything, helps relieve the pain?

  • Does pain affect the ability to do daily activities or to interact with other people? Does it affect sleep, appetite, and bowel and bladder function? If so, how?

  • Does pain affect mood and sense of well-being? Is the pain accompanied by feelings of depression or anxiety?

To evaluate the severity of pain, doctors sometimes use a scale of 0 (none) to 10 (severe) or ask the person to describe the pain as mild, moderate, severe, or excruciating. For children or for people who have difficulty communicating (for example, because of a stroke), drawings of faces in a series—from smiling to frowning and crying—can be used to determine the severity of pain.

Doctors always try to determine whether a physical disorder is causing the pain. Many chronic disorders (such as cancer, arthritis, sickle cell anemia, and inflammatory bowel disease) cause pain, as do acute disorders (such as wounds, burns, torn muscles, broken bones, sprained ligaments, appendicitis, kidney stones, and a heart attack). Doctors use specific techniques to check for sources of pain. Doctors move the person’s arms and legs through their normal range of motion to see if these motions cause pain. Injury, repetitive stress, chronic pain, and other disorders can make certain areas of the body (called trigger points) become hypersensitive. Doctors touch various spots to see whether they are trigger points for pain. Different objects (such as a blunt key and a sharp pin) may be touched to the skin to check for loss of sensation or abnormal perceptions.

Doctors also consider psychologic causes. Psychologic factors (such as depression and anxiety) can worsen pain. Sometimes pain is determined to be caused mostly or completely by psychologic factors. Such pain is called psychogenic pain. Because depression and anxiety may result from chronic pain, distinguishing cause and effect may be difficult.

Doctors ask about which drugs (including over-the-counter drugs) and other treatments the person has used to treat the pain and whether they are effective.

Few people exaggerate the pain they feel. Nonetheless, doctors usually also ask questions to make sure there are no ulterior motives for reporting pain, such as time off from work with pay or extra attention from family members. Such questions are routine.