COMMENTARY

The Fifth Vital SignWhat Does

It Mean?
Mohammad Sami Walid, MD, PhD*; Stephen N. Donahue, BS

;
Dana M. Darmohray, BA

; Leon A. Hyer Jr, PhD

;
Joe Sam Robinson Jr, MD, FACS

*Research Fellow, Medical Center of Central Georgia, Macon, Georgia;

Mercer University,
Macon, Georgia;

Neuropsychologist, Georgia Neurosurgical Institute, Macon, Georgia;

President, Georgia Neurosurgical Institute, Macon, Georgia, U.S.A.

Abstract: Acute pain is reported as a presenting
symptom in over 80% of physician visits. Chronic pain affects
an estimated 76.2 million Americansmore than diabetes,
heart disease, and cancer combined. It has been estimated to
be undertreated in up to 80% of patients in some settings.
Pain costs the American public more than $100 billion each
year in health care, compensation, and litigation. Thats why
pain was ofcially declared The Fifth Vital Sign. Hence-
forth the evaluation of pain became a requirement of proper
patient care as important and basic as the assessment and
management of temperature, blood pressure, respiratory
rate, and heart rate. The numeric pain scale certainly has a
place in care and in pain management; however, it is im-
portant to assess the patients communication and self-
management style and to recognize that patients, like pain,
are on a continuum with varied styles of communication and
adaptation. It is easy to get lost in the process, even when the
process is initiated with the best of intentions. In the quest
for individualized medicine, it might be best to keep pain
assessment in the individualization arena.
Key Words: pain scale, vital sign, objective, subjective,
compassion
INTRODUCTION
One of the most common reasons people seek medical
care is pain. Acute pain is reported as a presenting
symptom in over 80% of physician visits. Chronic pain
affects an estimated 76.2 million Americansmore than
diabetes, heart disease, and cancer combined.
1
It has
been estimated to be undertreated in up to 80% of
patients in some settings.
2
Pain costs the American
public more than $100 billion each year in health care,
compensation and litigation.
3
Recently, the management
of pain has reached the forefront of regulatory agencies
such as the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO), American Pain
Society (APS), National Committee for Quality Assur-
ance, and Center for Medicare/Medicaid Services,
making pain a priority with regard to education, mea-
surement, assessment, and documentation.
4
Chronologically, the process of improved pain recog-
nition started in 1992 when the clinical practice guide-
line was developed under the sponsorship of the Agency
for Health Care Policy and Research, Public Health
Service, U.S. Department of Health and Human Ser-
vices.
5
In 1994, the Board of Registered Nursing of
California adopted a pain management policy for regis-
tered nurse (RN) practice and pain management cur-
riculum guidelines for nursing programs.
6
Both of these
documents included a standard of care for California
Address correspondence and reprint requests to: Mohammad Sami
Walid, MD, PhD, Medical Center of Central Georgia, 840 Pine Street, Suite
880, Macon, GA 31201, U.S.A. E-mail: [email protected].
Submitted: March 9, 2008; Accepted: June 7, 2008
DOI. 10.1111/j.1533-2500.2008.00222.x
2008 World Institute of Pain, 1530-7085/08/$15.00
Pain Practice, Volume 8, Issue 6, 2008 417422
RNs of assessing pain and evaluating response to pain
management interventions using a standard pain man-
agement scale based on patient self-report.
In 1995, APS voiced the slogan pain: the fth vital
sign to elevate awareness of pain treatment among
health care professionals.
7
In 1999, JCAHO issued a
press release noting that unrelieved pain had physi-
cal and psychological consequences on patients and
increased health care costs.
8
JCAHO at that time of-
cially declared pain to be The Fifth Vital Sign, hence-
forth regarding the evaluation of pain a routine
requirement of proper patient care as important and
basic as the assessment and management of tempera-
ture, blood pressure, respiratory rate, and heart rate.
The Veterans Health Administration (VHA) added
pain as the Fifth Vital Sign as of October 2000.
9
Since
then, therapeutic advances, outcome studies, and the
publication of JCAHO Pain Management Standard for
2001 have rened the practice of pain treatment.
10
It
aims to develop a systematic approach to pain manage-
ment that assures that this problem is recognized and
treated promptly and effectively. This guideline is part of
a system-wide approach to pain management that is
designed to reduce suffering for patients experiencing
acute and chronic pain.
Legislators now encourage state medical and nursing
boards to develop guidelines for pain and symptom
management and to evaluate the conduct of practitio-
ners. Knowledge about palliative care has become a
condition of licensure. These new guidelines place a
similar requirement on licensed health care facilities.
Nursing programs need to integrate pain as the Fifth
Vital Sign into their curriculum, and health facilities
need to educate staff regarding pain management.
It seems clear that the motivation of JCAHO was to
develop pain assessment and management standards
due to an undertreatment of pain.
11
As implied, extant
studies carried out over the last 25 years have docu-
mented the undertreatment of both acute and chronic
pain. The JCAHO and VHA then adopted a logical
approach to identifying patients suffering from pain by
requiring that accredited hospitals and clinics obtain a
pain measurement along with the four standard vital
signs. The underlying assumption is that measurement,
identication, and documentation of patients in pain
should lead to improved management. According to
Noe et al, 2002, postoperative pain management at
Baylor University Medical Center has improved signi-
cantly over the past 5 years with the implementation
of new JCAHO standards and requirements in pain
management. The most signicant difference in the
past 5 years has been the amount of time patients
spent in moderate to severe pain (P = 0.000001). This
is a tribute to the more aggressive assessment and
treatment of pain by nurses and the increased famil-
iarity regarding newer pain management techniques by
physicians.
12
However, research has not always sup-
ported this presumption. One study performed in 2005
at a single VA clinic in Los Angeles found that the
quality of pain care was unchanged between visits
before and after the pain initiative (P > 0.05).
13
The
authors stated that, Routinely measuring pain by the
5th vital sign did not increase the quality of pain man-
agement. Patients with substantial pain documented by
the 5th vital sign often had inadequate pain manage-
ment. Apparently, additional measures are needed in
order to assure that patients suffering from pain are
recognized and treated accordingly.
In fact, since the implementation of pain as the Fifth
Vital Sign, it has been hard to nd evidence that this or
other related guidelines created by the JCAHO actually
serve to the betterment of the patient population. What
can be said is that they have increased costs for hospitals
and clinics that have had to implement the recommen-
dations set forth by the JCAHOwhich accredits 80%
of hospitals in the United States comprising 98% of
hospital beds. These recommendations include, but are
not limited to: educating providers and assuring staff
competency; establishing policies that support appropri-
ate prescription or ordering of pain medicine; educating
patients and families; and collecting data to monitor the
effectiveness and appropriateness of pain management;
and monitoring these efforts.
PAIN SCALES
Numerous pain scales have been developed. A sampling
is provided in Table 1. We think that one of the major
shortcomings of most pain scales is the lack of accuracy
necessary to use them for the proper treatment and
management of patients in pain. What exactly are we
measuring?
Pain is not a homogeneous percept. It is an unpleas-
ant emotional experience that varies between individu-
als. The majority of pain scales are unidimensional; ie,
they measure one dimension of pain, either intensity or
length. Most of them, actually, only evaluate the inten-
sity of acute pain upon admission to hospital.
The processing models of the experience of pain per-
turbation articulate well this complexity. In one model
of pain (reective of many models in the past two
418 walid et al.
decades) Wade and Price addressed the sensory,
cognitiveevaluative, and affective motivational dimen-
sions of pain.
14
There are four parts. First, there is the
sensory discriminative dimension, which consists of
spatial, temporal, and intensive sensation. This is mea-
sured by the visual and verbal analogs of pain. It is a
straightforward nociceptive reaction to a stimulus. The
second stage reects immediate unpleasantness (the rst
stage of affective processing), and it consists of per-
ceived degree of distress, annoyance, intrusion, or threat
intimately associated with pain. This stage has only
limited cognitive processing and can also be assessed by
the visual/verbal analogs. Studies that reect neural
activity within the brain by use of positron emission
tomography (PET) conrm that there are selective
neural modulation patterns, one in the anterior cingu-
late cortex and one in the somatosensory areas, for each
of the rst two stages.
15
This suggests that these are
separate higher cortical brain regions involved in the
experience of the two pain stages. The third stage of
this model involves suffering. It is closely related to
meaning and implications that pain holds for ones life.
Here ones attitudes, beliefs, and memories bear on the
adaptation to this stage. It has been shown that rating of
selected emotions and illness beliefs represent a psycho-
logical stage that is unique and separate from the rst
stages.
11
Finally, the last stage involves the overt behav-
ioral expression of pain. This involves illness behavior,
reected in activities of daily living (ADLs) and instru-
mental ADLs (this model has been supported by conr-
matory LISREL modeling).
10
NEEDED CORRECTIONS
First, there is the issue of chronic pain. This state ampli-
es measurement problems. Chronic pain is dened by
the U.S. National Center for Health Statistics as one
lasting 3 months or more. It is not uncommon for indi-
viduals to report different amounts of pain on different
occasions even if they are suffering from the same
amount of pathology. It is more common for chronic
pain patients to over-report pain levels, rating 10 on all
occasions. This happens for a number of reasons, espe-
cially characteristic of chronic pain, including psycho-
logical state, mood, affect, etc. While pain is subjective
and cannot be measured uniformly,
16
once person vari-
ables are involved, inaccurate results ensue. The experi-
ence of a long-lasting pain experience seems to result in
apperceived values, the nature of which eludes objective
measurement; yet pain cannot be effectively treated or
relieved unless it is measured.
Second, the experience of pain and its reporting is
culturally interactive. Measurement of pain is con-
founded by the healthcare professionals own predispo-
sitions toward the patient. In this context, the absence
of behavioral and physiologic experience of pain does
not necessarily mean the absence of pain. A patients
gender can have an effect on how the patients pain is
interpreted by the physician. Women seek help for pain
more frequently than men, but they are less likely to
receive treatment. Physicians often assume that either
women can handle more pain, or they are exaggerating
the level of pain they experience.
17
Women are more
likely to be given sedatives for their pain while men are
more likely to be given analgesics.
18
Substantial gaps in
knowledge exist regarding the management of pain in
elderly patients also; including determining the reliabil-
ity and validity of tools for the institutionalized or
community dwelling elder; modifying instruments to
overcome barriers such as communication issues, cul-
tural diversity, or cognitive dysfunction; and expanding
the scope of pain measurement to other dimensions of
the pain experience.
19
Third and related to two, professionals have differing
views of pain. The management of a patients pain,
whether it is acute or chronic in nature, is complex
because pain presents to physicians in many different
Table 1. A Representative Variety of Pain Scales
Pain Scale Type of Scale
Verbal descriptor scale Descriptive, unidimentional
MPQ Descriptive, unidimentional
Schmidt sting pain index Descriptive, unidimentional
0 to 10 pain scale Numerical, unidimentional
Brief pain inventory Numerical, unidimentional
Visual analog scale Visual, unidimentional
Wong-Baker faces scale Visual, unidimentional
Walid-Robinson index Numerical, bidimentional
Pain intensity upon admission (from
0 to 10) Length of pain suffering
(in months)
Brief battery for
health improvement 2
The test evaluate for a number of
psychomedical factors, such as pain,
somatic, and functional complaintsas
well as traditional psychological concerns
such as depression, anxiety and patient
defensiveness.
Multidimensional
affect and pain scale
A descendent of MPQ, but it covers more
territory, and does so in a
mathematically and sophisticated
manner.
Memorial symptom
assessment scale
A 32-item verbal rating scale that measures
psychological and physical symptoms
with regard to their presence, frequency,
severity, and degree of distress
associated with them.
MPQ, McGill pain questionnaire.
Pain as Fifth Vital Sign 419
ways. Interpretation of this presentation is the basis for
an effective treatment plan for the patient. For some,
this is the only marker of health; for others, it is an
annoyance in the care equation. For many years, blood
pressure, pulse, respiration, and temperature have been
dened as the basic Vital Signs that are used in the
assessment of a patients well being. Now pain is added
as the Fifth Vital Sign. Pain interpretation, if used prop-
erly, has been shown to be a useful tool for both moni-
toring the patients health state and the proper im-
plementation of pain management. We also know that
effective pain management is associated with patient
satisfaction, earlier mobilization, shortened hospital
stay, and reduced costs. That said, pain is also not an
absolute veridical marker of health, and outcomes
related to care utilization and psychological well-being
often suffer.
The fourth issue involves the phenomology of care. In
the Journal of Clinical Oncology 2007
20
a social worker
recounted her experience regarding the 0 to 10 pain
scale. Her experience of severe pain in the hospital and
her suffering experience were effectively erased by the
care-providers insistence on talking only about her pain
rating. Interestingly, she has no complaints about her
actual pain managementpeople took her seriously and
treated her appropriately. It was the lack of validation
and humanness about her experience that she felt like
the 0 to 10 scale engendered.
Fifth, the measurement of pain can be improved upon
and involves other correlates of the person. The Walid-
Robinson Index
21,22
was recently suggested as a simple
method to measure chronic pain, accounting for both
chronicity and intensity. While still imperfect, as it does
not account for the full subjective experience, it is an
attempt to improve on the objective features of pain
experience. In an effort to better account for this,
omnibus measures that address coping, personality,
and treatment prognostics, have been developed. These
address psychological issues of the person that ll out
necessary person-traits related to the experience of
pain. However, all these scales were not well validated;
they were not objectively investigated in terms of heart
rate, blood pressure, level of catecholamines in the
blood, brain wave or PET changes. Besides, some
of them are time-consuming and difcult to apply
routinely.
NECESSARY EVIL
As physicians began to recognize pain as an important
area for clinical intervention, the pain scale moved into
mainstream medicine. The intention was to give cre-
dence to the patients experience of pain and to provide
the patient and the clinician a meaningful place to ini-
tiate discussion of and intervention in the pain process.
It is a concrete acknowledgment that, while my crushed
nger may look clinically just like your crushed nger,
my pain response, my experience of the crushedness,
may be very different from yours and that both are
equally valid. Clinicians acknowledge the individuality
of the pain experience. Patients have their uniqueness
validated. They share an objective tool to evaluate a
subjective experience.
In response to the acute pain, nursing staff and phy-
sicians then ask the patient to rate their pain. Rating the
pain is somewhat like a process of investigating it with
your mind to evaluating your tolerance of it and
whether or not you are at a point of needing pain
medication. You try to describe your pain but the
medical staff usually say, No, dont describe it. Rate it
from 0 to 10. Sometimes, these conversations are ini-
tiated by the patient pressing the call button on the bed
because of pain. Other times, they are initiated by the
staffs responsibility to record the patients status. After
the patient gives a number, the staff are uniformly
responsive in offering medications. No one challenges
the number. In one sense this validates the reality of the
patients experience of pain and honors his or her
autonomy. However as just learned, we should be
careful that a tool developed to open and enhance
patientclinician communication, not substitutes for
other, needed communication.
SOLUTION
The pain scale was rst developed as a well-intentioned
effort to assist patients in communicating their pain
level to medical personnel. It gave the staff and patients
common ground to discuss and validate this highly sub-
jective experience. As such, it was a meaningful step in
honoring the subjective experience of pain and validat-
ing patients perception of pain. The addition involves
an investment in processing the patients pain with him
or her, in helping him or her differentiate between tol-
erable and intolerable pain. What is an extra-ordinarily
gray area for the patient is reduced to a black and white
decision tree for the staff: how quantiable is his or her
pain? If medication is indicated, how much and of what
kind? The patient may even appreciate what it would
take for a 7 to be a 6. The patient also appreciates
that in the main no one challenges his or her interpre-
tation of the severity of pain. The patient may wish,
420 walid et al.
however, that there were exploratory, evaluative discus-
sion that would serve as a model for the patient in
long-term pain management.
Everyone of us remembers how the hurts of child-
hood were magically healed by a caring adult kissing it
and making it all better. What those childhood encoun-
ters exemplify is the healing benet of caring presence
without the applications of any tinctures other than
compassion. Sometimes, consoling presence is the
needed medicationsomething the patient does not nd
in reporting and noting scores of 0 to 10.
The use of the 0-to-10-pain scale then as a sole
measure of pain assessment undercuts compassionate
communication. We understand that the pain scale is
now a mandated part of record keeping to meet licens-
ing standards. What is lacking is that, in that step, use
of the scale may unintentionally deteriorate into a
bureaucratic checklist item supplanting, rather than
enhancing, communication. In the process, several
things can be lost: the subtlety of individual experi-
ence, the opportunity for process and integration, and
meaningful dialog. This can result in a missed oppor-
tunity to explore the meaning of suffering and to help
the patient to differentiate between pain and suffering.
When the patient is in the grip of acute pain, it is easy
to lose sight of that difference. Compassionate conver-
sation can restore the patients balance in a way that
picking a number does not. Patients need physicians
who sit and listen, who are willing to talk about what
causes particular types of pain and to evaluate the
effects of pain on other areas of the patients life, who
help assess and redene, through conversation, what is
tolerable and what needs pharmacologic intervention
and inform them about their choices with dignity and
integrity.
CONCLUSION
The concern is that we may inadvertently put modern
medicine out of touch with the patient. The numeric
pain scale certainly has a place in care and in pain
management; however, it is important to assess the
patients communication and self-management style, to
recognize that patients, like pain, are on a continuum
with varied styles of communication and adaptation.
Some patients may be quite comfortable with the scale
as their whole communication method; however, for
other patients it may be an inadequate frustrating
obstacle instead of a tool. It is easy to get lost in the
process, even when the process is initiated with the best
of intentions. In the quest for individualized medicine, it
might be best to keep pain assessment in the individu-
alization arena.
Aristotle classied pain, like pleasure, as a passion
of the soul, which today would be translated to a
state of feeling. Aristotles description of pain as
having an emotional component is one that is still accu-
rate today. Thats why some authors agree on using the
capital P to dene the word Pain, to underlie the deep
emotional meaning of the suffering experience which
goes beyond the physical symptoms.
23
Our lack of
understanding of the manifestation of pain in the human
body as a whole experience (enveloping the physical as
well as the mental state of the patient) still leaves much
to be desired in assessment of pain before we can truly
use pain as a diagnostic tool.
Our understanding of pain has advanced signicantly
from the time of Aristotle, although the denition may
have not changed much in the last 2,300 years. A
welcome reminder that as clinicians, faced with the suf-
fering of our patients, our impulse to measure, inter-
vene, and x needs to be tempered by our deeper
mandate to listen, console, and offer presence. Pain has
the dignity of a true state of life and, as such, we believe
it deserves our full respect.
REFERENCES
1. American Pain Foundation. Pain facts and gures.
Available at: http://www.painfoundation.org/page.asp?le=
Newsroom/PainFacts.htm. Accessed February, 2008.
2. Kirsch B, Berdine H, Zablotsky D, et al. Manage-
ment strategy: identifying pain as the fth vital sign. VHSJ.
2000;4959.
3. National Institutes of Health. NIH guide: new direc-
tions in pain research I. Available at: http://grants.nih.gov/
grants/guide/pa-les/PA-98-102.html. Accessed September 4,
1998.
4. Cruz MA. Acute pain management: an emergency
department perspective. Emergency Medicine Reports, July-
2004. Available at: http://www.accessmylibrary.com/coms2/
summary_0286-13000586_ITM Accessed December 2, 2007.
5. Agency for Health Care Policy and Research
(AHCPR). AHCPR Clinical Practice Guideline, Acute Pain
Management: Operative or Medical Procedures and Trauma.
Silver Spring, MD: U. S. Department of Health and Human
Services; 1992.
6. Pain assessment: the fth vital sign. The BRN
Report. 2000;31. Available at: http://www.rn.ca.gov/pdfs/
forms/brn500.pdf. Accessed July 9, 2008.
7. Campbell J. Pain: the fth vital sign. Presidential
address, American Pain Society, Los Angeles, California, Nov
11, 1995.
Pain as Fifth Vital Sign 421
8. Dahl J. Implementing the JCAHO pain manage-
ment standards. American Pain Society 19th Annual Meeting
November 25, 2000, Atlanta, Georgia. Available at: http://
www.medscape.com/viewarticle/420351. Accessed July 9,
2007.
9. JCAHO. Joint commission focuses on pain manage-
ment. Report of the Joint Commission on Accreditation of
Healthcare Organizations, Washington DC, 1999.
10. VHA. Pain as the 5th Vital Sign Toolkit. Washing-
ton, DC: National Pain Management Coordinating Commit-
tee; 2000.
11. Merritt D, Lynn J. State initiatives in end-of-life care:
policy guide for state legislators. National Conference of State
Legislatures and Center to Improve Care for the Dying. Wash-
ington, DC, 1998. ISBN 1-55516-762-4. Available at: http://
www.ncsl.org/programs/pubs/comp1.pdf. Accessed December
2, 2007.
12. Noe CE, Haynsworth RF, Ramsay MAE, et al. Out-
comes of a pain management educational initiative at Baylor
University Medical Center. Proc (Bayl Univ Med Cent).
2002;15:35.
13. Mularski RA, White-Chu F, Overbay D, Miller L,
Asch SM, Ganzini L. Measuring pain as the fth vital sign does
not improve quality of pain management. J Gen Intern Med.
2006;21: 607612.
14. Wade J, Price D. Nonpathological factors in chronic
pain: implications for assessment and treatment. In: Gatchel
R., Weisberg J, eds. Personality Characteristics of Patients
with Pain. Washington, DC: American Psychological Associa-
tion; 2000.
15. Rainville P, Duncan G, Price D, Carrier B, Bushnell
M. Pain effect encoded in human anterior cingulated but not
somatosensory cortex. Science. 1997;277:968971.
16. Gatchel RJ, Weisberg JN. Personality characteristics
of patients with pain. American Psychological Association
(APA) February ISBN 978-1557986467; 2000.
17. Hoffman DE, Tarzian AJ. The girl who cried pain: a
bias against women in the treatment of pain. J Law Med
Ethics. 2001;29:1327.
18. Calderon KL. The inuence of gender on the fre-
quency of pain and sedative medication administered to post-
operative patients. Sex Roles. 1990;23: 713725.
19. Rodriguez CS. Pain measurement in the elderly: a
review. Pain Manag Nurs. 2001;2:3846.
20. Chauhan C. The perception of perception. J Clin
Oncol. 2007;25: 23292330.
21. Walid MS, Hyer LA, Ajjan M, Barth ACM,
Robinson JS. Prevalence of opioid-dependence in spine surgery
patients and correlation with length of stay. J Opioid. Manag.
2007;3:127128;130132.
22. Walid MS, Hyer LA, Ajjan M, Robinson JS.
Predicting opioid-dependence using pain intensity and length
of pain suffering in pre-spine-surgery patients. Internet J
Pain Symptom Control and Palliative Care 2007;5.
23. Morris DB. Living Pain: Mystery or Puzzle? The
Culture of Pain. Berkeley, CA: University of California Press;
1991:116. ISBN 0520082761.
422 walid et al.