Original Article

Influence of interpretation of pain scores on patients’

perception of pain: A prospective study

Sumitra G Bakshi, Akanksha Rathod, Supriya Salunkhe

Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital and Homi Bhabha National
Address for correspondence: Institute, Mumbai, Maharashtra, India
Dr. Sumitra Bakshi,
Department of Anaesthesia,
Critical Care and Pain, ABSTRACT
Tata Memorial Hospital
and Homi Bhabha National Background and Aims: Assessment of pain using pain scales is essential. In the Numeric
Institute, E Borges Road,
Parel, Mumbai ‑ 400 012,
Rating Scale (NRS), patients are asked to score their pain intensity on a scale from 0
Maharashtra, India. to 10 (10‑ worst pain). This requires some abstract thinking by the patient, also the pain
E‑mail: sumitrabakshi@yahoo. scores (PS) may not essentially communicate the patients’ need for more analgesia. We
in
planned a study to evaluate the change in patients’ self‑assessed PS after understanding
Submitted: 11‑Feb‑2021 clinical interpretation of the NRS.Methods: This prospective study was registered after
Revised: 16‑Feb‑2021
approval from our hospital ethics board. Sample size estimated for the trial was 360 patients.
Accepted: 22‑Feb‑2021
Published: 13-Mar-2021 All postoperative patients were recruited after informed consent. Patients having prolonged
stay in Intensive Care Unit (more than 48 h), or those who underwent emergency surgeries
were excluded. During Acute Pain Service (APS) rounds, patients were asked to rate their
Access this article online PS on the NRS. This was followed by a briefing about the clinical interpretation of the scale,
Website: www.ijaweb.org and the patients were asked to re score their pain using the same scale. The change in pain
severity was compared using Chi‑square test. Results: Following explanation, a change in
DOI: 10.4103/ija.IJA_130_21
severity was seen for PS at rest [X2 (9, N‑ 360) = 441, P < 0.001] and at movement [X2 (9,
Quick response code
N‑ 360) = 508, P < 0.001].Overall, a change in PS severity was seen in 162 patients (45%).
A decrease and an increase in the severity of pain was seen in 119 and 41 patients respectively.
Conclusion: Explaining the clinical interpretation of PS on a NRS does lead to a change in
patients’ self‑assessed PS.

Key words: Acute pain, pain scale, pain services, pain severity, pain scores, postoperative pain

INTRODUCTION difficult to interpret. While using the NRS, the patient

could possibly be worried about the score correctly
Acute postoperative pain management is a dynamic communicating the need for analgesia.[5] In addition,
process and requires assessment and reassessment.[1] the NRS scores are not interchangeable, and similar
Incorporation of pain as the “fifth vital sign” requires scores in different patients and in the same patient at
adaptation and acceptance of user‑friendly scales.[2] different time points could mean different degrees of
The Numeric Rating Scale (NRS, 0-10) is a widely used pain.[4] Communication at times may not be complete,
instrument for pain screening because of its ease of even in adults when it comes to quantifying and
administration. NRS is simple, easy and can be used concluding about the need for analgesia.[4]
even in the absence of any physical scale.[3] In NRS,
patients are asked to score their pain on a scale from 0 This is an open access journal, and articles are distributed under the terms of
the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License,
to 10, 0 representing “no pain” and 10 being “the worst which allows others to remix, tweak, and build upon the work non‑commercially,
pain possible.”[3] Only whole numbers are to be used as long as appropriate credit is given and the new creations are licensed under
the identical terms.
to represent pain in this scale.
For reprints contact: [email protected]

NRS reflects the change in the severity of pain based How to cite this article: Bakshi SG, Rathod A, Salunkhe S. Influence
on the increase or decrease in scores.[4] The clinical of interpretation of pain scores on patients’ perception of pain:
importance of changes from the baseline may be A prospective study. Indian J Anaesth 2021;65:216-20.

216 © 2021 Indian Journal of Anaesthesia | Published by Wolters Kluwer - Medknow

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 Bakshi, et al.: Understanding patients’ pain perception

Appropriate communication is essential between from 4 to 6, implying moderate pain suggesting that
the patient and treating physician to ensure that the an increase or change in pain medications is needed.
right amount of analgesics is provided.[6] If analgesics PS from 7 to 10, implying severe pain which indicates
are prescribed solely based on the NRS response, a need for immediate medication/intervention.[4,6]
there remains a potential risk of over‑treatment The explanation was given orally, in the language
or under‑treatment.[7] Hence, additional dialogues best understood by the patient and/or their relative.
and observations are necessary to allow patients to Following the explanation, patients were then asked
express their pain in detail and to ensure optimum to rate their PS using NRS for pain at rest and at
pain relief.[1] It becomes essential for the health care movement. An independent observer recorded the PS
providers to explain the pain scale in a way that pre-explanation and post-explanation. Any change in
the patient understands, and guides in effectively severity of PS after explanation was noted. The APS
changing the postoperative pain management. This team was entitled to make necessary changes in pain
study was planned to evaluate the change in patients’ management after complete evaluation and at their
self‑assessed pain scores (PS) after understanding the clinical discretion.
clinical interpretation of the pain scale.
Later, the APS team was asked if the PS post‑explanation
The primary objective of this study was to evaluate was “beneficial” or not. For this study, “beneficial”
the change in patients’ self‑rated PS after a brief information was defined as information which helped
explanation of the clinical interpretation of PS by in deciding/re‑enforcing (when in doubt) the changes
caregivers. The secondary objectives were to find out that were needed in the pain management plan.
if the caregivers found this communication beneficial
and in addition, to understand its impact on pain Previous studies have shown an overtreatment in
treatment. around 30% of patients, because of disparity in
interpretation of pain scales between patient and
METHODS caregiver.[8] A sample size of 341 was required as per
Clopper‑Pearson method to test the primary objective of
After approval by the hospital ethics board, this the trial which was to study the change in patients’ pain
prospective intermittent time series study was severity (mild/moderate/severe) after the explanation.
registered with the Clinical Trial Registry of India The sample size was calculated using a precision
(CTRI/2017/08/009305). The study was conducted width of 0.1 and a two‑sided 95% confidence interval.
between August 2017 and January 2018. All Allowing a 5% chance of data loss in view of the patient
postoperative adult patients on their first/second not communicating/comprehending the NRS pain
postoperative day in the surgical wards and under scales, a total sample size of 360 patients was planned.
the care of the Acute Pain Service (APS) team of
our hospital were included in this study after taking For analysis, PS was entered as categories: mild (1 3),
informed consent. Those patients who had a prolonged moderate (4‑6), severe (7‑10).[9,10] Change in severity of
stay in the post-anaesthesia care unit (more than 48 h), PS after explanation was taken as an event and expressed
and those who underwent emergency surgeries were as percentage. Pre and post‑explanation pain severity
excluded. was compared using Chi‑square test, expressed as X2
(degree of freedom‑ df, sample size‑N) = Chi‑square
During the pain rounds, as a part of our routine value, P value. The number of patients in whom the
practice, the patients were asked to rate their PS on the PS after explanation were found to be beneficial to
NRS, which is a 11‑point pain scale, for measuring pain the caregivers was expressed as a percentage. All data
severity (0 = no pain and 10 = worst possible pain), was analysed using International Business Machine
at rest and at movement. After recording the patients’ Statistical Package for the Social Sciences (IBM®
response, a member of the APS team explained the SPSS) version 21. For all data, P value <0.05 was
clinician’s perspective of patients’ PS.[4,6] considered as statistically significant.

The explanation mainly included the following‑ As there could be potential bias in the results during
PS‑ from 1to 3, implying mild pain, suggesting that consenting for participation in the trial, the consenting
the ongoing pain medications are effective and no process was done in two steps as per the direction of
further increase in pain medication is necessary. PS our institutional review board. The informed consent

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 Bakshi, et al.: Understanding patients’ pain perception

for participation in the trial was taken a day prior during movement, while in the remaining 45 patients,
to surgery from the patients posted for major and the severity of pain during rest and movement changed
supra‑major surgeries and in whom APS follow‑up post-explanation. A decrease and an increase in
was expected as per the existing protocols. The initial severity of pain was found in 119 and 41 patients,
consenting process included an overall view of the respectively. The rest scores reduced in two patients,
study explaining mainly post-operative pain and PS. but the severity of pain at movement increased after
Finer details like the actual clinical interpretation explanation.
of PS were not revealed at this stage. Following
recruitment and recording of PS, a debriefing consent We looked at factors which influenced the change
was re‑ obtained and patient data was used. Feedback in severity of PS post‑explanation. There was no
was taken only once from each adult patient. association between change in PS post‑explanation and
gender (P = 0.48), the time of interview (P = 0.058) or
RESULTS pain management modality (P = 0.21). When asked if
the information was useful, the APS team found the
468 patients were screened and expressed their information post‑explanation to be beneficial in 71%
willingness to participate in the trial. 360 were of cases.
included after exclusion [Figure 1]. A near‑equal
gender distribution was seen in the study participants DISCUSSION
[Table 1].
Explaining the clinical interpretation of PS did lead
Pain was analysed at rest and at movement.There to a change in severity of pain in nearly half of the
was a significant change in severity of pain at rest study population (45%). In 119 patients, a decrease in
post‑explanation, X2 (9, N‑360) = 441, P < 0.001 pain severity was seen and hence these patients were
[Table 2]. Similarly, for severity of pain during at risk for over‑treatment. In 41 patients, an increase in
movement, the change was statistically significant, severity of pain was found, and this group was at risk
X2 (9, N‑360) = 508, P < 0.001. Overall, a change of under‑treatment of pain using the traditional NRS
in severity of PS was seen in 162 patients (45%). In system for pain assessment.
42 patients, there was a change in pain severity with
pain at rest; in 75 patients the change was seen in PS NRS is one of the most widely used scales. Evidence
supports the reliability of NRS in adults and in patients

Table 1: Demographic and surgical details of participants

Variable Number of
patients (n)
n %
Age Mean (±SD) 47 (±15)
Range 18‑82
Gender Male 186 52
Female 174 48
Patients Day 1 207 58
assessed on Day 2 153 42
Postoperative
day
Pain Epidural Analgesia 169 47
management PCA 31 9
Epidural analgesia+PCA 07 2
Regional Analgesia 22 6
Others (Round the clock analgesic) 131 36
Surgical Unit Gastrointestinal 134 37
Gynaecology 75 21
Bone and soft tissue 57 16
Thoracic 48 13
Urology 42 12
Others 4 1
%‑ number of patients expressed as percentage. SD ‑ Standard deviation .
Figure 1: CONSORT diagram for recruitment of patients in the trial PCA ‑ Patient controlled analgesia

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 Bakshi, et al.: Understanding patients’ pain perception

Table 2: Impact of clinical interpretation of pain scores on patients’ perception of pain

Pain scores
At rest At movement
Pre‑ explanation Post‑ explanation Pre‑ explanation Post‑ explanation
Severity of pain None 11 11 3 3
(%of patients) Mild 55 66 35 44
Moderate 30 20 48 46
Severe 4 3 14 7
P (Chi‑ square test) X2 (9, n=360) = 441, P<0.001 X2 (9, n=360) = 508, P<0.001

with low health literacy.[11] It is also an appropriate tool suggests that the additional communication did help
for assessment in older patients.[12] In a previous study, the APS team members in decision‑making and/or
it was seen that with the assumption of moderate reinforcing their treatment plan.
pain for scores more than 3, 30% of the patients who
considered their pain to be bearable, would wrongly Numerous types of pain scales are available for
be classified as having unbearable pain, leading to clinical use.[20‑22] One can argue that the inadequacy of
over‑treatment. Similarly, 3% of patients would be interpretation of PS is restricted to the NRS and that
assumed to have bearable pain though they were having other scales[23,24] like the objective pain score[4] could
unbearable pain, thus leading to under‑treatment of be more suitable tools to be adapted. However, even
pain.[8] A similar result was seen by the same group with the use of more objective scores, there still lies a
of investigators in the geriatric population.[7] There gap between the caregivers’ interpretation of need of
is a potential risk of inappropriate treatment, if the rescue analgesic and severity of pain at rest or deep
pain is assessed wholly by the number provided by coughing.[7,13] Though the effect of communication
the patient.[13] It is essential that the caregivers should has been studied with respect to the NRS in our
communicate in detail and assess the patients’ entire study, it may also prove to be beneficial with the use
pain experience rather than prescribing analgesics of other scales as it tries to bridge the gap and helps
based on a single numeric response.[12,14,15] Frequent and in understanding the severity of pain and need for
thorough assessment of patients’ pain would ensure additional analgesics. Hence, we strongly feel that
optimal pain management.[16,17] The communication communication could be used as a second step to
between patient and health care professionals is enhance the process of pain assessment following the
aided by the use of pain scales.[14,15,18] However, use of any suitable pain assessment tool. Based on our
there can be a discordance in the interpretation clinical experience, we believe that the difference in
of pain assessment between the patient and the interpretation of PS between patient and caregiver and
caregiver.[14,19] The caregivers must realise that patients subsequently better communication lead to a change
can have their own interpretation of the pain scale in PS post-explanation. To elaborate, in patients in
and their own perception with respect to the NRS whom the severity of PS does not match with the
score while correlating with the need for additional clinicians’ expectation of mobilisation, a briefing about
analgesics.[10,13,14,16] interpretation of PS can help in understanding the
patients’ need for additional analgesia; for example,
The potential risk of under‑treatment is a possibility the patient may have pain during coughing but it may
with some patients who hesitate to choose a high not be severe enough to need a rescue analgesic.[7]
score fearing disbelief by the physicians.[12] Explaining
both ends of the spectrum despite low pain scores Following explanation, we found an increase in
does reassure the patient that high pain scores are not reporting of mild pain, with patients realising that high
unexpected. This could be the reason why, in a few scores could lead to overtreatment with analgesics.
patients, we had increase in severity in pain scores However, the possibility that the patients reported low
after explanation. scores because they actually thought that analgesics
could cause harm and side effects cannot be ruled
In this study, we have explored the effect of clinical out.[7,12] The fact that, we had few patients going up on
interpretation of PS on patients’ self-rated pain the PS reinforces that fear of analgesic in our patient
perception. The feedback from the APS team was population did not play a major role. However, this was
positive with the team members reporting the not prospectively asked for and remains a limitation of
communication as beneficial in 71% of the cases. This our study. Another limitation includes the failure to

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