Pain Assessment Tools

In order to identify how pain is assessed and interpreted currently,  I have gathered different pain assessment tools used in medical settings now. Some of these examples are from the U.K., and they do not seem to be utilized in the U.S. yet. In this way, I will be able to discover possible pain points of the LEP patients in pain communication.

McGill Pain Index


What is working?

This pain index contextualizes pain for others. Even though not everyone has experienced or will experience labor pain, by showing organizing different pain in a 0 to 50 scale, one can compare different pain and estimate the level of pain his or her pain.

What is missing?

This focuses on the magnitude or level of the pain rather than the individuality of different of pains, which means that one cannot express what kind of pain one feels.

McGill Pain Questionnaires

McGillForm  SF-MPQ2McGillPainChart

What is working?

McGill Pain Questionnaire sorted different pain descriptors and categorized and arranged them into different of hierarchies.

What is missing?

This assessment tool cannot be used if you do not speak English. It is translated into some languages.  But, I doubt the availability of these forms in different languages at the provider’s offices in the U.S. For LEP patient, these subtle differences are not easily communicative and comprehensible.

VAS Scale

What is working?

One of the most common tools used around the world. Some visual elements (smiling or frowning face), portray the pain along with the numbers.

What is missing?

Again, this only deals with the magnitude of the pain. A patient can only determine the intensity of the pain based on their past experiences. So, pain magnitude is individualistic. A provider cannot determine if one patient’s 7 and other patient’s 7 are the same.

Pain Scale


What is working?

Even though there is no smiley and frowny faces, this pain scale gives more context to the scale by having explanations and examples of pain level next to the number.

What is missing?

Again, this only deals with the magnitude of the pain, not what kind of the pain, one feels. Other than the color and numerical portion, this scale relies on language proficiency of the patient. Plus, this can be most useful when the patient and provider are language concordant.




What is working?

Pain-QuILT a Web-Based Visual Pain Assessment Tool in Adults With Chronic Pain. This method allows patients to quickly describe, log and track what kind of pain they feel, where the pain is as well as the magnitude. The best part of this method is the metaphors. Not only descriptors are visual but also easy to understand, which means that patient is not required to understand the words to comprehend the meaning.

What is missing?

This focuses on chronic pain, therefore, it does not ask the patient about other relevant pain information such as the duration, frequency, aggravators, relievers and etc.

Show Me Where


What is working?

Having something tangible and visual to communicate with the provider enhances the overall quality of the face to face communication between the patient and provider. The app version offers 12 other languages other than English. Plus, it has two different versions one for the Adult and one for Child. The visual language is simple yet factual.

What is missing?

Personally, I feel like the location of the pain is easier to communicate than the kind and description of the pain. Even when there is a language barrier, one can point and show the location of the pain. But, how and what kind of pain one feels is very difficult to explain without proper language skills.



What is working?

Used with the intensity scale, OLDCART can help identify basic factual information about the pain. The beginning, location, duration, characteristics, aggravators, and relievers, as well as the treatment type, can be distinguished.

What is missing?

Neither verbal nor written communication help LEP patients. Without knowing the English words, one cannot communicate any of information OLDCART can help identify. I wonder if there is a list of pain characteristics or descriptors they use.

PQRST Pain Assessment Method

P = Provocation/Palliation

What were you doing when the pain started? What caused it? What makes it better or worse? What seems to trigger it? Stress? Position? Certain activities?

What relieves it? Medications, massage, heat/cold, changing position, being active, resting?

What aggravates it? Movement, bending, lying down, walking, standing?

Q = Quality/Quantity

What does it feel like? Use words to describe the pain such as sharp, dull, stabbing, burning, crushing, throbbing, nauseating, shooting, twisting or stretching.

R = Region/Radiation

Where is the pain located? Does the pain radiate? Where? Does it feel like it travels/moves around? Did it start elsewhere and is now localized to one spot?

S = Severity Scale

How severe is the pain on a scale of 0 to 10, with zero being no pain and 10 being the worst pain ever? Does it interfere with activities? How bad is it at its worst? Does it force you to sit down, lie down, slow down? How long does an episode last?

T = Timing

When/at what time did the pain start? How long did it last? How often does it occur: hourly? daily? weekly? monthly? Is it sudden or gradual? What were you doing when you first experienced it? When do you usually experience it: daytime? night? early morning? Are you ever awakened by it? Does it lead to anything else? Is it accompanied by other signs and symptoms? Does it ever occur before, during or after meals? Does it occur seasonally?


What is working?

Very detailed set of questions which can gather important factual information of the pain. This method affirms that the severity of the pain is not the only thing to be determined from a patient in order to accurately diagnosis the pain.

What is missing?

This method still relies on verbal communication, which is difficult for the LEP patient. But I can make sure to incorporate some of these indicators to my project.


Pictograms, Icons, and Illustrations

Pictograms – Otl Aicher Munich Olympic 

One of the most famous pictograms of all time is 1972 Munich Olympic Pictograms by Otl Aicher. It is amazing how he captured the dynamic movements of various sports in such a simple and clean manner.

Grid System


The consistency of the pictograms was possible thanks to careful use of the grid system. Otl Aicher used on grid system to create more than 700 pictograms. These pictograms were created decades ago, but still applicable and modern. His grid system consists of square and triangle, which enhanced the energetic angle of the pictograms still consistent and align as one whole system.

A pictogram’s quality is articulated in its simplicity.

You can find more Otl Aicher’s pictograms here. The pictograms are categorized into 9 categories: Sports, Communication & Media, Health & Hygiene, Security, Shop & Gastronomy, Culture & Leisure, Services, Transport & Traffic, and Miscellaneous. Here are some of my favorite health & hygiene pictograms.

Screen Shot 2018-01-27 at 9.37.45 AMScreen Shot 2018-01-27 at 9.38.06 AM

Icons – The Noun Project

To see how pain is visualized by different graphic designers around the world, I searched different keywords about pain on The Noun Project.


Even though there is a commonality (thunder-like shapes or sharp lines) in how pain is portrayed, the individuality of different pains is not visualized in precise or detailed manner.

Illustrations – Widgit-Health Communication Book

Due to the complexity of medical situations, it is very difficult to portray medical terms and situations in a very simple manner such as pictograms and symbols. Therefore, an illustration is a better style of visualization.

A British company called Widgit Health uses simple illustrations to help communications between patient and providers. The slideshow below includes English, Dutch, French and Polish version of General Questions sheet.

This slideshow requires JavaScript.


  • Pain is often visualized as sharp lines, thunder-like shapes, and frowning faces.
  • Sometimes, pictograms and icons are too simple to encompass the complexity of medical situations.
  • Color is very powerful, which can add depth of meaning.

Visualization vs. Words

Point it: Traveller’s Language Kit is a book by Dieter M. Gräf. This book is a great example, which shows that visualization is much more universal and powerful when there is a language barrier.

I was first introduced to this book from Korean website, which described this book as a perfect solution when you do not know the language of the foreign country you are visiting. This can be quicker than using Google Translate or other translation application. Just point what you need along with the body language. This book acts as a visual dictionary. Instead of forming a sentence using words, you can just point to the object or other representation of place, food and etc to communicate.

visualization > words

Similar concept of using visualization rather than words was used in ICONSPEAK


Between, Point it and ICONSPEAK, I personally think using Point it is more effective and more accurate since it is consist of the actual photographs of objects rather than icons. Due to the simplicity of the icons, sometimes meaning can be interpreted differently. Plus, Point it includes more items, which acts as more options. Items are grouped with other items often associated together by different situtaitons. This adds context to the items, which encourages more comprehensive communication.

Even before Point it and ICONSPEAK, we used pictograms to communicate universal meaning. These pictograms can be found at the airports, restrooms, Olympic or other global events and etc.

What’s next?
History of pictograms?

Brain Dump



Fall 2017 Recap 3 – Semiotics of Pain

Visual Analogue Scale (VAS)

One of the most common medical symptoms is a pain, and the differences between various pains can be very slight and very difficult to describe or explain. For patients with Limited English Proficiency (LEP), it is even more difficult to communicate different kinds of pain to language discordant providers. To help LEP patients, I visualized different kinds of pain.


It is difficult to explain and describe pain especially for non-English speaker


Help non-English speaking patients to communicate their pain with healthcare providers easily






  • Color is very important
  • Animation can add more details and dimensions to the visualization
  • Drawing or painting can be therapeutic
  • Asking patients to draw the pain can reveal more about the pain they are experiencing
  • It is difficult to distinguish between kinds of pains
    EX) tugging vs pulling, burning vs searing

Fall 2017 Recap 2 – American Healthcare System

“Healthcare quality is emotion and experience-driven rather than fact-driven” 

Emily Friedman

The iron triangle of the healthcare includes Quality, Access, and Cost. These are also the main goals of healthcare, but only two of them exist together at the same time.


American Healthcare System is complicated and hard to navigate to English proficient Americans. We can only imagine how hard it would be for ones with Limited English Proficiency (LEP). In America, more than 20% of Americans speak languages other than English at home.


And about half of Texas has more than 35% county speaks a language other than English at home (see picture below).FA2017_semester.025.jpeg

This means about half of Texans are at the risk of adverse effects of the language barrier in different medical situations.

Adverse effects of language barrier

  • Makes harder to access care
  • Lowers patient satisfaction
  • Worsens conditions by not getting appropriate care at the right time
  • Decreases health literacy
  • Lowers utilization of care both preventive care and regular care
  • Raises non-compliance
  • Heightens risk of being misunderstood by their physicians
  • Increases medical errors and drug complications

Medical Interpretation in the U.S.

    • Title VI of the U.S. Civil Rights
    • The law requires physicians to offer ‘qualified’ interpreters and translators to patients with limited English proficiency (LEP) when doing so is necessary


    • Even telephone interpretation services about
      $2-3 per minute without a contract


  • Patient speaks different languages. More than 100 different languages are spoken in the U.S.
  • Language services are not reimbursed
  • Lack of professional medical interpreter services

Medical interpreter or language line services are current solutions to language barrier in the medical situation but with the emergence of technology such as AI, virtual health and telehealth, government, insurance companies and other healthcare enterprises need to spend more effort, time and resources to improve and develop solutions to this serious and prevalent issue.

Possible solutions

  • Better utilization of interpreters
    • Arrange contracted hours per week for most prominent language
    • Community-based providers and a shared interpreter bank
  • Training and utilization of medical staffs
    • Bilingual PA/RN special interpretation training
    • Training physicians to work effectively with interpreters- by speaking in short, clear sentences and avoiding medical jargon, also improves communication and increases time available for patients to ask questions or make statement
  • Technology
    • Translation apps: Canopy Speak, Canopy Quest and Canopy Learn
    • Meducation : allow access to a database of translated written prescriptions to be deployed in pharmacy applications
    • Telehealth/ Virtual visits

Fall 2017 Recap 1 – Social Science Method

In Fall 2017 semester, I focused on gaining more knowledge in American Healthcare System and narrowing down and solidifying my thesis topic.

One of the key problems I identified and want to improve is adverse effects of a language barrier in Healthcare. Langauge barrier worsens social and racial disparities, health literacy and self-agency of patients with Limited English Proficiency (LEP).


Effects of Language Barrier

  • Disparities – Language barrier limits the access to the healthcare, lowers the utilization of preventive services, as a result, worsens health outcomes.
  • Language concordance/Discordance – Language discordant patient more likely to visit ER (Manson, 1988) and lowers patient’s satisfaction.
  • Health Literacy is a capacity to obtain, process and understand basic health information and services to make appropriate health decisions. LEP patients have much lower health literacy due to the limited access to health education.
  • Patient-Provider Communication – Lack of fluid communication in the medical situation impacts LEP patients’ health outcomes. Language barrier increases the risk of adverse medication reaction (Wilson, 2005).
  • Self-Agency is a capacity of individuals to act independently and to make their own free choices. LEP patients tend to have lower self-care agency.

Just having English-only options on important and resourceful websites such as patient portal, insurance website and patient education websites, can contribute to the exacerbation of the language barrier yet in digital space as well, where translation technology already exists.