Monday, July 22, 2013


Pain Behaviors are the actions that people perform to communicate that they are suffering with pain.  Whenever I ask patients how their friends and family know that they are hurting, most reply "They just know."  If I prod a little, most people can point to one or more things that the do to communicate that they are in pain.

Here are some common pain behaviors I have noticed in my practice. Which of these do you recognize from your own experience?
  • Grunting
  • Grimacing
  • Standing
  • Shifting
  • Rubbing
  • Limping
  • Postural or gait changes
  • Crying
  • Sighing
  • Bracing (clutching or holding on to furniture, equipment, or affected area during movement)
  • Using heat or ice packs
  • Using assistive devices such as crutches, walkers, wheelchairs, TENS unit
  • Reclining
What Influences Pain Behaviors

1.    Pain behaviors serve a function at first. (i.e. Limping and Guarding)
2.    They then can cause problems.
3.    People do not show pain behaviors just to “get attention.”
4.   You should ask yourself "At this point in time, is this behavior helping me or hurting me?"

  1. If something desirable happens following a pain behavior, that pain behavior is more likely to occur in the future. If something undesirable stops following a pain behavior, that pain behavior is more likely to occur in the future. Ignoring a pain behavior should decrease the occurrence of that behavior.

 So why is it important to recognize pain behaviors?  

1.  Pain Behaviors are Ambiguous.  How is your family supposed to know what you need when you elicit a pain behavior unless you tell them.  For example, pain behaviors can mean mean different things:
  • "I hurt"
  • "Help me"
  • "I need you"
  • "Leave me alone"
  • "Come closer"
  • "I can't do___ today"
  • "Don't expect much from me"
2. Pain Behaviors Are Powerful.  Recent research has demonstrated that viewing pain behaviors in others produces measurable changes in our brain and cardiac activity.  This suggests a hard-wired predisposition to react to pain in others. This means that people may not respond to you in the way you intended.


1.  Identify Pain Behaviors:  Pay attention to the things you do when you are hurting, and more importantly, pay attention to the response you get from people close to you.
2. Eliminate Pain Behaviors:  
  •  PT/OT
  • Improve posture
  • Decrease narcotic pain medication usage
  • Avoid unnecessary rest
  • Get involved in other activities via distraction
  • Avoid talking about the pain
  • Remind those close to you what you need
For more information contact Dr. Wolfson at  Or visit:

Tuesday, June 18, 2013

Using the Fitbit to Track Pain, Sleep, and Activity

Using the Fitbit in a Program to Track Pain, Sleep, and Activity

I have been fascinated with the Fitbit activity tracker ever since I purchased my first one over a year ago.  Since that time, Fitbit has updated the form factor twice, most recently releasing the Fitbit Flex.

As a psychologist who specializes in assessing and treating people who have chronic pain, I have fought for years to identify smart ways to track my patients' sleep, activity, and pain ratings to help them develop a clear path out of the often debilitating cycle of pain/inactivity/depression that develops when coping with a chronic health problems.

When I was trained initially at the University of Washington, we were taught to ask patients to track their activity and pain using paper and pencil forms like the one shown here:
I used to ask patients to fill out these questionnaires to tell me how many minutes they spent sitting vs. reclining vs. walking for every hour of the day (for seven days).  I would also ask them to tell me their hourly pain rating, and indicate when they took their medicines.  As you can imagine, the compliance rates were horrible!  I cannot tell you how many times I saw patients sitting in my waiting room filling out the sheets for the entire preceding week.

Being somewhat of a tech nerd, I figured "well, I'll just put together an awesome website that patients can log into and fill in their data at home." Makes sense right? However, the compliance rates with web-based data entry were even worse than with the paper and pencil measures.

I began experimenting with giving my patients the fitbit about six or eight months ago, and have been blown away by the results.  The units allow me to collect sleep and activity data which we supplement with pain ratings collected via SMS text messaging.  Finally I have been able to collect the information I need to help patients see where they are, so together we can develop a road map toward increased functioning and overall greater wellness.

 I am now trying to improve the technology for widespread distribution and need your help.  If you are a patient suffering with chronic pain and would like to try the fitbit/SMS program to assess your pain, please contact me.  There is no cost to you (aside from normal texting charges).  Or, if you are interested in just learning more about my program, I am happy to discuss it with you.

Find me at or email at or @painrpa.

Monday, April 29, 2013

Why Rating Your Pain is Important

When patients complain of pain to their doctors, the first question usually asked is "How would you rate your pain on a scale from 0-10?"  Although on the surface, this appears to be a relatively straight-forward question, there are actually many factors that impact the individual's response.

Why do doctors ask about pain ratings? Doctors are interested in your pain rating for a number of reasons.  First, the quality of your pain can help give hints as to what is the pain generator.  For example, burning, tingling, and shooting types of pain can be indicative of nerve damage or compromise.  The location of your pain is important as well, as this can give a doctor valuable information about the medical issue.  Poorly localized pain described with the words squeezing, cramping, pressure, or deep can point to organ dysfunction, fibromyalgia or lupus, while well-localized pain described as dull, achy, throbbing, and sore can foretell a musculoskeletal injury, or CRPS.

Besides the quality of the pain, doctors want to know the intensity or strength of your pain.  Questions of intensity help make pre and post-comparisons of various treatments as a way to objectively describe pain levels.

Visual Analog Scales ask the patient to draw a line to signify the intensity of their pain that is then measured with a ruler.  Solves the ratio problem, but patients generally do not use the full length of available values.
 Visual Analog Scale
Numerical Rating Scales ask patients to quantify the strength of their pain using numbers spaced at fixed intervals.  Although this is a very common method of rating pain intensity, there is a misconception that differences between numerical labels are equa (ratios), making direct comparison difficult.

Functional Pain Rating Scales tie pain levels to functional activities.  These occasionally offer a much richer description of how the pain is impacting your ability to live life and care for yourself. Below is an example of a comparative rating scale adapted from from A. Rich, Lucile Packard Children’s Hospital.
So, the next time your doctor asks you to rate your pain level, keep in mind what he or she is really asking and use a pain rating scale that fits your needs.  For more information go to or follow us on twitter @painrpa
Comparative Pain Scale

No Pain. Feeling Normal
Does not interfere with most activities. Able to adapt to pain psychologically and with medication or adaptive equipment
Very Mild
Very light, barely noticeably pain, like a mosquito bite or poison ivy itch.  Easy to forget about the pain
Minor pain, like lightly pinching the fold of skin between the thumb and first finger with the other hand, using fingernails.
Very noticeable pain, like an accidental cut, a blow to the nose drawing blood, or a doctor giving an injection.  The pain is not so strong that you cannot adapt to it.  Eventually, most of the time you don’t notice the pain
Interferes with many activities. Requires lifestyle changes but patient remains independent. Unable to fully adapt to the pain.
Strong, deep pain, like an average toothache, the initial pain from a bee sting, or minor trauma or part of the body, such as stubbing a toe.  This is like firmly pinching the fold of skin between the thumb and first finger with the other hand, using fingernails.
Very Distressing
Strong, deep, piercing pain, such as a sprained ankle or mild back pain.  Not only do you notice the pain all the time, you are now so preoccupied with managing it that your normal lifestyle is curtailed.
Strong, deep piercing pain so strong it dominates your senses and impairs cognition.  Difficulty holding a job, maintaining normal social relationships.  Similar to a bad non-migraine headache
Unable to engage in normal activities.  Person is disabled and unable to function independently.
Very Intense
Same as 6 except pain completely dominates the senses causing unclear thought more than 50% of the time.  Similar to average migraine headache
Pain so intense you cannot think clearly at all, and experience significant personality change similar to behavior during childbirth.
Pain so intense you cannot tolerate it and demand pain medication or surgery, no matter the side effects or risk.  Complete absence of joy, similar to throat cancer
Pain so intense you will go unconscious shortly.  Most people have never experienced this level of pain.