Why put a number on pain?
Scoring pain serves three purposes: to decide on a treatment and how intensive it should be, to track how well that treatment works over time, and to communicate unambiguously between clinicians. Pain that is never assessed is almost always under-treated.
The founding principle is self-report: the reference is what the patient says, not what the clinician observes. Observational assessment of behaviour is used only when communication is impossible — an infant, an older person with cognitive impairment, a patient in intensive care.
Validated assessment scales
Numeric rating scale (NRS)
“On a scale of 0 to 10, how bad is your pain right now?” 0 means no pain and 10 the worst pain imaginable. Simple and usable over the telephone, it is the tool most widely used in practice.
Visual analogue scale (VAS)
A 10 cm line with no visible markings; the patient moves a pointer and the clinician reads the value on the back. Very sensitive to change, but it does require a good grasp of the abstraction.
Verbal rating scale (VRS)
Five words: none, mild, moderate, severe, very severe. Invaluable for older people, or for anyone who struggles with numbers.
DN4 questionnaire
Ten items — seven on the description, three on the examination — to screen for a neuropathic component. A score of at least 4 out of 10 points towards specific treatment.
McGill Pain Questionnaire
A list of sensory and affective descriptors from which the patient chooses. It enriches the description and is valuable in complex pain.
Behavioural scales
The Abbey Pain Scale and PAINAD for older people who cannot communicate, FLACC and the Faces Pain Scale – Revised for children: they score facial expression, vocalisation, posture and movement.
Interpreting the score
| Score (0–10) | Intensity | Usual approach |
|---|---|---|
| 0 | No pain | Monitor |
| 1 to 3 | Mild pain | Simple painkiller, non-drug measures |
| 4 to 6 | Moderate pain | Tailored treatment and early review; the threshold above which action is needed |
| 7 to 10 | Severe pain | Urgent management, reassessment at 30–60 minutes |
What happens in a pain consultation
The history takes up most of the time: far more than any scan, it is what identifies the mechanism.
The story of the pain
How long have you had it? How did it start? Where is it and where does it spread to? What does it feel like — burning, a vice, a shock, a throb? What eases it and what makes it worse? How does it change through the day?
The impact
Sleep, appetite, mood, physical activity, work, family and social life. This part counts as much as the intensity when deciding on treatment.
The examination
Inspection, palpation, movement, neurological testing: muscle power, reflexes, sensation to touch, to cold and to pinprick, and a search for allodynia by brushing the skin.
Further tests
Ordered only if they will change what is done: blood tests, imaging, nerve conduction studies. In the absence of red flags they are often unnecessary and sometimes harmful.
The treatment plan
Realistic, functional goals — climbing the stairs, sleeping six hours, going back to work part-time — rather than the sole promise of a zero out of ten. A date for review is agreed.
Keeping a pain diary
This is the most useful thing a patient can bring to an appointment. For one or two weeks, note down each day:
- the intensity from 0 to 10, in the morning, the afternoon and the evening;
- the location, using a body chart if that helps;
- the medicines actually taken, the time and the effect obtained;
- what you did during the day and how well you slept;
- what set the pain off and what relieved it.
This record turns a vague impression into usable data, and it often reveals patterns that go unnoticed day to day: pain peaking in the late afternoon, a link with a working posture, a medicine that genuinely works but for far too short a time.
Frequently asked questions
Is there a test that proves pain exists?
No. No blood test, no scan and no other investigation measures pain itself. Tests look for a possible cause; a normal result never invalidates the complaint. Self-report remains the reference standard.
Should I exaggerate to be taken seriously?
No, and it backfires. A consistent score, tracked over time and set alongside the concrete impact on your activities, is far more convincing and far more useful for adjusting the treatment.
How is pain assessed in someone who cannot speak?
With validated observational scales that score facial expression, vocalisation, guarding, body position and behaviour during care: the Abbey Pain Scale and PAINAD in older adults, FLACC and the Faces Pain Scale – Revised in children.
What is a pain clinic?
A hospital-based multidisciplinary service — pain consultant, specialist nurse, psychologist, physiotherapist — for chronic pain that has not responded to usual care. Access is normally by referral from a GP or another specialist.
Sources and references
- IASP — Pain assessment tools and guidance on self-report.
- Bouhassira D. et al., DN4: validation of a screening tool for neuropathic pain.
- British Pain Society and Faculty of Pain Medicine — outcome measures in chronic pain.
- Herr K. et al., Pain assessment in the patient unable to self-report.