Recognizing Nonverbal Signs of Pain

"Pain is a more terrible lord of mankind than death itself"

So said Albert Schweitzer. The existence and intensity of pain often goes unmentioned verbally due to severe physical weakness or mere incapability of some patients to express anything on account of their infancy or other physical restraints. However, it is possible for the medical team to look out for some key aspects in the person's gestures that indicate existence of intense pain. Family members who are closely associated with the patient can easily differentiate between a patient's normal behavior and gestures, and the ones when the patient is feeling discomfort. So what exactly should one look out for?

Recognizing Signs of Pain

Pain in Infants and Toddlers
Infants and toddlers do not possess the required communication skills to inform their caregivers about the existence of pain or the intensity of experienced pain for that matter. The ability to verbally express pain comes by the age of two while ability to quantify pain comes by the age of three only. Till then, it is best for parents and medical experts to rely on some non-verbal signs expressed by children. Some common non-verbal signs are changes in facial expressions, changes in physical movement, incessant crying, change in muscle tone and body posture, etc. Some noteworthy changes in facial expressions include forming of vertical furrow, lowering of eyes, tight closure of eyes and raised cheeks, furrow between upper lip and nose and wide opening of mouth. Other signs include high-pitched incessant crying, psycho-motor inertia and wariness to move. Infants also tend to be irritable and restless with an agitated facial expression, show lack of interest in their surroundings, show blank expressions and withdrawal symptoms. At times, the toddlers may also get unnaturally clingy to a comforting parent especially mothers. These infants may also get protective of the painful area.

Pain in Adults
Some of the most common non-verbal expressions of pain amongst adults include changes in respiratory rate, heart rate and saturation of oxygen. Other common signs include facial grimacing, moaning and groaning, restlessness and agitated facial expression, constant shifting in chair or on the bed, writhing, guarding the painful area and general withdrawal symptoms. A severity of pain may be a cause for lack of interest in surroundings and a change in appetite. There is a noticeable fall in energy and enthusiasm levels. Another non-verbal display of pain could be when patients absent-mindedly crumple a piece of paper or fabric in their hands or toes so as to shift the stress caused by pain.

Scientific Techniques for Pain Assessment

Defining Severity of Pain
At times, it is easy to recognize the existence of pain but it is difficult to find out its severity. For all those adults who are unable to tell the extent of pain, doctors have a technique based on ratings of pain on a scale of 0 to 10. Here '0' is regarded as no pain at all, while a rating of '10' refers to a worst case of pain. When patient rates his pain levels between 1 to 3 it is considered as mild pain, between 4 to 7 is moderate pain, while 8 to 9 is referred to as a severe case of pain.

In case of toddlers, who are able to grasp language but are still unable to express the severity of pain, doctors use a technique called Wong-Baker faces pain rating scale. The technique involves a set of four facial pictures ranging from a smiley face to a crying face. The child is asked to pick out the picture that best describes the level of its pain. A smiley face picture is considered as non-existence of pain while a crying face picture is considered as the most severe case of pain.

Toleration Level of Pain
The toleration level to bear pain differs from person to person. Although '0' level best describes the absence of pain, it is often noticed that this no pain level may stretch up to rating '3' in many persons. Doctors need to carefully scrutinize the pain level based on tolerance study and prescribe medications accordingly.

Recognizing Pain as per Disease
When we notice that, existence of pain along with its extent or its location are not verbally expressed, it is often best to rely on the symptoms and previously recorded medical cases. For example, a heart attack is bound to give chest pain while a case of liver cirrhosis might mean severe pain in upper right abdomen. Caregivers should be alert to recognize situation of pain triggers in certain patients. For example, a patient may experience acute pain whenever he sleeps on his left side.

Shocking as it might sound, there have been innumerable cases of death due to lack of expression of pain thereby delaying the process of medication. It is responsibility of family, friends and caregivers to be the patient's eyes and ears in identifying non-verbal signs of pain. The same may then be communicated to the doctors to start immediate treatment.