Pain is a necessary function of life and is as old as the earth, wind, and fire. It is an element of the human organism; pain protects us and is an early warning sign of danger to the body or organ systems. As I assure patients, pain is real and necessary. However, pain can also be unnecessary and, although it is as ubiquitous as the air we breathe, we must habitually ask our patients about the possibility of pain and treat it.
Like the oxygen we consume for life, pain is necessary for survival and resilience. Acute pain is definably a sentinel of danger, and chronic pain can be a constant reminder of pathology in the physical and the psychosocial sense. Like other qualitative phenomena, pain is extremely difficult to measure or to quantify. Even in light of advances in technology in the clinic (point of service), we rely on subjective measures for translating the patient's needs for the quantification, diagnosis, and treatment of pain.
The word "pain" comes from the Latin "poena," meaning a fine or a penalty. From a physiological standpoint, pain is an unpleasant sensation occurring in varying degrees of severity as a consequence of injury, disease, or emotional disorder. It is a neurophysiological phenomenon. The bottom line is that pain is one of those entities with a multitude of definitions and descriptors of which some could be classified as terminological inexactitudes!
The American Pain Society coined the phrase "pain: the fifth vital sign" to elevate awareness of pain treatment among healthcare professionals. The Joint Commission has declared that pain should be treated as a vital sign. The traditional vital signs-pulse, blood pressure, respiration, and temperature-are called signs for a reason. They follow the medical axiom that signs must be objective, measurable, and quantifiable. Pain is not a sign; it is a symptom. Symptoms are what patients describe, subjectively, as a feeling, and feelings are not easy to quantify. We should, however, measure and treat our patients' pain with the same degree of urgency as we do the other vital signs.
In practice, though, we attempt to make this subjective phenomenon more objective. We use various rating scales-typically, 1 to 10, with 1 being the least pain and 10 being the worst pain. Zero would indicate the absence of pain. We also ask about qualitative facets of the pain: the location, the time of onset, the duration, and the nature of the pain (sharp, burning, stabbing, shooting, dull, aching, throbbing, and pressure, to name a few). This gives us some clues and data to work with, which is a start. Although pain is not a clinical sign in the traditional sense, it is a patient's early warning system that an underlying problem-one that may be life threatening-does exist. As healthcare providers, we need to pay attention to this warning, including when evaluating and treating chronic wounds. Unfortunately, we have had a paucity of scientific guidance in the chronic wound care literature. However, as a journal, Advances in Skin & Wound Care is trying to add to the discourse about wound pain. In fact, this month's continuing education article, on page 373, addresses acute wound pain.
We can all agree that pain is undertreated and sometimes underrated. This is not surprising. As a society, we face significant challenges in the area of adequately treating pain. Barriers thrown up by our healthcare systems, other healthcare professionals, laws and regulatory issues, the attitude of patients and families, and society itself thwart our ability to provide adequate pain relief. Sadly, patients who do not report pain and healthcare providers who fail to assess for pain are major contributors to this problem.
In any case, in wound management, we must recognize pain (in its many forms) and be habitual and proactive in treating patients by relieving pressure, prescribing, protecting, and proliferating healing with resultant prevention or resolution of wound pain and discomfort.
Great is the power of habit. It teaches us to bear fatigue and to despise wounds and pain. -Cicero.
Richard "Sal" Salcido, MD
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