Pain Fallacies

„And pain is all around” ~ Simon & Garfunkel, Bridge Over Troubled Water

Rheuminating pain / As fog and rain return / But the foliage ~ Haiku

The most stupid thing a physician can do, when treating pain patients, is to doubt pain. Pain is a subjective feeling and only the person experiencing pain can tell you if it hurts, where it hurts, and how much it hurts. Doubting pain hurts, too!

1^st Fallacy: “I don’t see anything on the X-ray!” – so you shouldn’t complain about pain. I call it the orthopaedics’ fallacy, because lots of patients with low back pain encounter such an attitude. But there’s another trap: any degenerative sign in an X-ray chart may serve as an explanation for pain; often too easy an explanation for chronic pain, which is complex.

2^nd Fallacy: “But there’s no inflammation!” – and so you shouldn’t complain about pain. I call it the rheumatologists’ fallacy, because that’s a trap we might fall in. Sometimes inflammation is below detection limit, sometimes we haven’t used all technical equipment like high frequency ultrasound or MRI. Sometimes there isn’t any autoimmune driven inflammation, but there might be pain due to mutilations or post arthritic osteoarthritis. All need extra care!

3^rd Fallacy: “If there’s pain, there has to be something wrong!” I might call it the chronic pain fallacy. It’s a trap for physicians and patients as well. After a good diagnostic one shouldn’t turn to more aggressive diagnostic procedures, as this might more harm than yield results. Chronic pain is a disease of its’ own, which gets worse, when there’s input by acute pain, but which doesn’t need this input to hurt badly all over. A good example is fibromyalgia.

Some pains are due to undetected inflammation and need more anti-inflammatory measures.

Some pains might need a change of drug.

Some pains might need a change of attitude.

Let us physicians keep in mind to believe in the pains that patients bring to us!

Pain Assessment at our Center (1st Visit)

When patients come to our center for the first time, they might not know,  how to talk about their pain. Nearly all patients coming to see a rheumatologist for the first time come beause of pain. Every patient receives a 5 pages questionnaire to assess symptoms, a pain inventory, drugs, allergies, and so on, a HAQ, and a pain manniquin.

Short questionnaire to assess your pain

How much pain did you have?

0  1   2   3   4   5   6   7   8   9   10
no pain                                      great pain

How much fatigue did you have?
0   1   2   3   4   5   6   7   8   9   10
No fatigue                                  great fatigue

Where did the pain start? (open question)
Since when do you have pain? (open question)
I there a certain time of  the day, when pain is especially intense? (open question)
What would you character your pain? pulling, stabbing, burning, boring, cutting, unpleasant, disturbing, annoying (and more, open for addional characteristics)
What relieves the symptoms? (open question)

What enhances the complaints? (open question)



When taking the patient's history we can take this as a starting point for questions to get a deeper knowledge. For instance strongest and weakest pain during the past 24 hour or week to look for fluctuations.

All in all this small inventory has helped to get started with assessing pain.