PI Brief Update

'15 out of 10!': Making Sense of Pain Scores - Dr Mark Burgin

25/02/22. Dr. Mark Burgin BM BCh (oxon) MRCGP explains how to resolve inconsistencies in the pain score given by claimants in PI assessments.

The typical visual analogue scale runs from 1 (mild) through 5 (moderate) to 10 (severe) and is commonly used a short cut to assessing pain.

Some scores appear inconsistent with the physiological state on examination or the medical treatment or disabling effects.

Drug seeking behaviour does not explain these inconsistencies in PI as the doctor is not able to prescribe in a medical examination.

Discussion with the claimants has given me some insight into their reasoning and why experts can be misled.

Different pain scales

Some claimants use a pain scale that is different from the expert running from 1 (mild) through 10 (severe) to 20 (extremely severe).

Their reasoning is that it makes no sense to stop at severe (10), pain can get worse so the scale should be extended to match.

The best approach to this problem is describe the pain using the claimant’s own words in quotation marks and include psychosocial aspects mentioned by the claimant.

This allows the expert to accurately record what the claimant said but avoid having to say that their assessment was not likely to be correct on the expert’s VAS.

At its worst

There is a well known advice to always describe pain at its worst and this makes some sense as the pain may completely resolve between attacks so the minimum is zero.

The pain may be continuous for the first weeks (7 out of 10) but then becomes a dull ache when bending once a week (7 out of 10) then an occasional sharp shooting feeling with heavy lifting in the gym (7 out of 10).

At its worst the pain remains (7 out of 10) but the character and the frequency has altered consistent with recovery.

Asking the claimant to explain these features of the pain can avoid an inconsistency emerging between increasingly less restricted activity but no change in the pain score.

Physical and Psychological Pain

The character of pain is changed by the psychological state of the person suffering it so that mild pain feels intolerable to a depressed person.

There is increasing evidence that psychological pain is ‘real’ in the sense that imaging can show changes such as ballooning of the heart with acute grief.

Allodynia is pain response from a stimulus which should not cause pain such as light touch and these claimants’ descriptions are consistent.

Typically these claimants are already under pain clinics and have diagnoses such as central pain sensitisation, fibromyalgia or regional pain syndrome.

Conclusions

Claimant’s resist the use of the VAS and can approach a request to rate pain as ‘ask a silly question’ so give a literally correct answer.

Uncritical acceptance of the word severe without trying to understand what the claimant means can lead to inconsistencies in the report.

For some claimants the accident has caused an intolerable worsening to previously controlled chronic pain that they struggle to find the words to describe.

A finding of 10 out of 10 pain should be the start rather than the end of a conversation about the claimant’s experience of pain.

Doctor Mark Burgin, BM BCh (oxon) MRCGP is on the General Practitioner Specialist Register.

Dr. Burgin can be contacted on This email address is being protected from spambots. You need JavaScript enabled to view it. and 0845 331 3304 website drmarkburgin.co.uk

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