The Perfect Ten

People can be so amazing. It’s only been done in gymnastics a hand full of times, but when a perfect ten is scored, it is recorded in the history books. The feat is extremely rare given the fact that there is a level of subjectivity with judging. For one person to say that a person performed a perfect routine is much easier than four people to agree that a person performed a perfect routine. Nadia Comaneci was the first to perform a perfect ten routine in Olympics gymnastics. The Olympics have been around since 1896, so when she did in 1976, people were confused. What did her score mean? On the scoreboard, it read 1.00, which translated to perfect. Romanians everywhere went crazy.

People can also be amazing for all the wrong reasons. When I asked Mario what his pain level was, he said, without hesitation “20” as he slouched back in the chair, not so much as a wince on his face. Mario was a sixty five year old Colombian patient of mine that was coming in for knee pain. He wasn’t in a wheelchair. He didn’t limp into the visit. I even saw him laughing with the medical assistant as he was walked into the room.

I told him that the scale only goes to “10,” to which he replied, “10 then.” After examining the knee in question, there was no edema, no erythema or redness. I wasn’t even able to elicit any pain in moving it. X-rays were subsequently negative. I diagnosed him with a sprain, prescribed him some anti-inflammatories, recommended he ice it and sent him on his way.

My friend’s daughter, who is eight, recently back flipped into a pool, but inadvertently hit her face on the edge of it, requiring two stitches on her nose. When she was asked to rate her pain at the emergency room, she said “4.” I compare the two of these people just to illustrate the stark differences between how pain is perceived.

The pain scale is part of the vital signs that are normally obtained at a doctor’s visit. It is the only vital sign that is completely subjective. When a patient tells me that their pain is a perfect ten, I wonder why they are sitting in an outpatient clinic with me instead of a hospital somewhere, comatose from the pain that they are supposedly in. It is a useless vital sign when patients describe their pain a ten. When pain is described as a ten, underlying issues that have nothing to do with pain are at work. There are usually elements of mood disorders and personality disorders at play, along with cultural perceptions of pain and what is considered normal. Occasionally, I’ll get a malingering patient, looking for some kind of fix. From my experience, the patients that tend to be the most honest with their pain are children. This is usually the case because most of them are unencumbered by neuroses and have only been introduced to the culture that they have been born into.

This isn’t to say that the pain scale is not entirely without merit when a patient tells me “10.” As I said, pain is subjective, and so, when a patient comes in with a “10,” it tells me that they are hurt in one way or another. It may not be to the level of hurt that I may expect, but it tells me that they are hurt nonetheless.

Pain also comes in a variety of flavors. The traditional pain is in the form of nocicepetive pain, which is accompanied by body tissue damage and is typically described as sharp, achy and throbbing. Neuropathic pain is when nerve damage is involved, and is typically described as burning or as a numbness. In addition, there are also pain syndromes, like reflex sympathetic dystrophy and fibromyalgia. These syndromes are more complicated in their presentation and treatment is variable depending on their severity.

Ultimately, however, pain is filtered through the prism of personality, mood, culture, religion, and body. Every person is unique, making it difficult to simplify pain into a number. When dealing with patients that have a “ten out of ten,” sometimes medication isn’t the first answer. Sometimes, just talking and reassuring a patient is enough to make the owwie go away. A true perfect ten, like Nadia Comaneci, is usually something we will only see once in a lifetime.

By: Dr. Juan Borja
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