By Dr Duncan Sanders, Physiotherapist
Dr Duncan Sanders is currently Senior Lecturer for the Master of Medicine (Pain Management) program at the University of Sydney, Co-Director of E3Physio.com.au, and practices at the Managing Pain Clinic.
A person comes into the clinic with ongoing knee pain. At the beginning of the consultation, we ask them to rate it on a scale from zero to ten.
“Seven,” they say.
It would be easy to assume that the most important clinical task is now to reduce that seven. But what if the person’s real concern is not the pain itself? What if they are worried that walking will make their knee worse, have stopped taking their children to the park, or no longer feel confident using the stairs at work?
The pain rating may open the conversation, but it rarely tells us where that conversation needs to go.
A useful measure with clear limits
Pain scales have an important place in clinical practice, maybe more so in acute pain. They provide a simple, shared language for discussing an experience we cannot directly observe. Used over time, they may also help us recognise changes and understand how someone is responding to care.
The difficulty arises when the score becomes the assessment rather than one part of it.
A rating given in the clinic is a snapshot shaped by the circumstances of that moment. It may reflect pain at rest, after a difficult journey, during a flare-up or in anticipation of an examination. Even the meaning of the scale can vary between people. One person’s seven cannot be neatly compared with another person’s seven.
This matters because a number can create a false sense of precision. It can draw our attention towards intensity while leaving the consequences of pain unexplored.
What has changed because of the pain?
In physiotherapy, we often learn more by asking what pain has changed than by asking only how much it hurts.
Can the person move in the ways they need to? Are they avoiding particular activities? Has their sleep been disrupted? Have they reduced their working hours, stopped exercising or withdrawn from social life? What do they believe is happening in their body, and how has that affected their confidence?
The answers help us understand the relationship between pain and the person’s daily life.
They may also reveal that pain intensity and disability are not moving together. Someone can experience considerable pain while remaining active and engaged. Another person with a lower rating may feel frightened, restricted and unable to participate in activities that matter deeply to them.
Neither experience is more or less legitimate. They simply require us to look beyond the score if we are to provide appropriate matched and personalised care.
Measuring progress differently
A narrow focus on pain intensity can also influence how we judge whether care is working.
Imagine that a person’s pain remains at five out of ten, but they are now walking to the local shops, sleeping more consistently and returning to a valued hobby, i.e. pain self-efficacy has improved. If our only outcome is the pain rating, we risk describing their treatment as unsuccessful.
From the person’s perspective, however, those changes may be enormously significant.
Meaningful improvement may include greater confidence in movement, less worry about pain, improved participation or an increased ability to manage difficult days. Recognising these outcomes does not mean pain relief is unimportant. It means agreeing with the person on a broader and more useful definition of progress.
This can change the direction of care. Instead of pursuing a lower number at all costs, clinician and patient can work together towards goals connected to function, wellbeing and everyday life.
Using the score to begin, not conclude
The value of any pain measure depends on what we do with the information it provides.
After asking, “How would you rate your pain?”, we might follow with:
- What is the pain making difficult for you?
- What have you stopped doing because of it?
- What are you most concerned the pain might mean?
- What would you like to be able to do more easily?
- What would worthwhile progress look like to you?
These questions place the score within the person’s physical, psychological and social context. They help us understand not only the presence of pain, but its significance.
The OPEN Clinical Pain Training Program supports clinicians to bring this wider perspective into practice through a structured approach to recognising, assessing and treating pain. This includes selecting appropriate measures, exploring the effect of pain across a person’s life and evaluating outcomes that are relevant to their goals.
A pain score can be useful. But its greatest value may be as an invitation to ask the next question, and then listen carefully to the answer.
