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Cited by 362Pain Management and Opioid UseAnesthesia and Pain ManagementPediatric Pain Management Techniques

Pain measures and cut-offs - 'no worse than mild pain' as a simple, universal outcome

Moore, R. A., Straube, S., Aldington, D.·2013·Anaesthesia
DOI 10.1111/anae.12148
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Abstract

Now admittedly the patient in question had undergone a life-saving operation in a brand new hospital staffed by some wonderful and talented people. However, a pain score of 6/10 is not mild, but borderline between moderate and severe, and the patient did need something for that. Was the nurse ignorant of what pain scores meant, or was it just that caring professionals typically underestimate patients' pain 1? Both these questions are deserving of research, but for this patient, the only point is that the system failed him, and for him the reasons behind the failure were of little interest. He had pain that was borderline severe, and it was not treated. This is not uncommon. A fairly recent survey of Italian hospital wards came to the hardly original conclusion that those wards in which less analgesic was prescribed had higher rates of patients experiencing severe pain than those where more analgesics were prescribed 2; Fig. 1 shows the clear inverse relationship between the presence of severe pain and the percentage of patients treated for their pain. There is a wealth of evidence that pain is poorly treated, and that significant proportions of patients suffer from moderate or severe pain, whether it is acute pain in hospital 3 or chronic pain in the community 4, 5. Barriers to progress are many and varied, but one particular and important barrier is a degree of confusion about pain scoring systems and what they mean. How does a simple categorical verbal rating system (no pain, mild, moderate, severe) relate to a 100-mm visual analogue scale (VAS) or an 11-point numerical rating scale (NRS)? Does it matter what the anchors are at each end? Where are the boundaries for moderate or severe pain? What is the minimal clinically significant difference? Does it matter whether the scale has been ‘validated’ in Welsh, or Farsi, or Urdu? All of which makes for terrific grist for the mill of grant applications, but does not make things easy for clinical practice, because it suggests that there is considerable uncertainty over pain measurement. Pain scales continue to proliferate, not least because they can be copyrighted and significant sums paid to use them in clinical trials, as do academic arguments about whether, on average, a few millimetres change on a 100-mm scale represents a useful outcome 6. One outcome of all this is additional uncertainty over which scale is ‘right’. All this academic angst is unimportant for everyday practice, where the simple question is whether pain is present at an unacceptable level or not. It may be time to consider a divorce between all these interesting academic complexities and the theoretically simple, but practically difficult requirements for successfully treating patients with pain. The philosophical principle of ontological parsimony, rather easier understood as keeping it simple, was suggested about 700 years ago by William of Ockham, and more recently restated as the KISS principle by Kelly Johnson 7. We (the authors) are increasingly of the opinion that in measuring pain there should be a simple principle – that only ‘no worse than mild pain’ is acceptable in clinical practice, and the important practical outcome of ‘no worse than mild pain’ is the only outcome of interest to be taken from clinical trials. We are relaxed about just how ‘no worse than mild pain’ is measured, but take the view that the borderline between mild and moderate pain is about 30 mm on the 100-mm VAS 8 in acute pain or 3/10 on a 0–10 NRS. Figure 2 shows data from almost 14 000 paired observations taken at rest or on activity over a 48-h postoperative period in surgical patients that would agree with 30 mm as a cut-off point (data from 9); other analyses give similar if slightly different cut-off points 10. There is some evidence that strict adherence to ‘no worse than mild pain’ principles can lead to virtual elimination of severe pain in hospital 11. The same cut-off point works well for chronic pain in the community 12, and pain measures work at least as well as more complicated scales in conditions such as inflammatory arthritis 13. Electronic searching alone is known to retrieve only a minority of observational studies relevant to a research question 14, 15. Experience shows that broader types of searching can capture many more studies 14, 16. We therefore conducted a search to find studies informing on the three main themes above. These searches comprised a series of different free text searches of PubMed (to November 2012), with follow-up on any potentially useful publication using the ‘related citation’ facility. For useful publications, we also checked on citations of that publication using Google Scholar™. In addition to electronic searches, retrieved articles were read for any other sources of data, as were general review articles and book chapters. When asked what they would consider treatment success, patients with chronic pain specify a large reduction in pain intensity, by 50% or more

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Authors
Moore, R. A., Straube, S., & Aldington, D.
Affiliations
  • University of Oxford (GB)
  • Universitätsmedizin Göttingen (DE)
  • Royal Hampshire County Hospital (GB)
Corresponding author
Moore, R. A.
ORCID
Venue
Anaesthesia
Publisher
Wiley
Published
2013-01-24
Volume
68
Issue
4
Pages
400-412
ISSN
  • 0003-2409 (ISSN-L)
  • 1365-2044
DOI
10.1111/anae.12148
OpenAlex
W1995021873
Cited by
362
References
81
Citations by year
2026: 9 · 2025: 17 · 2024: 16 · 2023: 23 · 2022: 17 · 2021: 20 · 2020: 18 · 2019: 20 · 2018: 26 · 2017: 55 · 2016: 34 · 2015: 51 · 2014: 34 · 2013: 20
FWCI
10.51
Type
journal article
Language
en
Open access
closed
Licence
onlinelibrary.wiley.com/termsAndConditions#vor (vor)
Locations
  • Anaesthesia (publishedVersion)
  • PubMed (publishedVersion)
  • GRO (submittedVersion)
Topics
  • Health Sciences › Medicine › Anesthesiology and Pain Medicine › Pain Management and Opioid Use
  • Health Sciences › Medicine › Surgery › Anesthesia and Pain Management
  • Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Pediatric Pain Management Techniques
Keywords
pain assessment, undertreatment of pain, analgesic prescribing, visual analogue scale, numerical rating scale, pain outcome measures, pain experience, barriers to pain treatment
MeSH terms
Analgesia, Humans, Pain, Pain Measurement, Severity of Illness Index, Patient Satisfaction

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