RESEARCH ARTICLE
The Colour of Pain: Can Patients Use Colour to Describe
Osteoarthritis Pain?
Vikki Wylde*, Victoria Wells, Samantha Dixon & Rachael Gooberman-Hill
Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Southmead Hospital, Bristol, UK
Abstract
Objective. The aim of the present study was to explore patients’ views on the acceptability and feasibility of using
colour to describe osteoarthritis (OA) pain, and whether colour could be used to communicate pain to healthcare
professionals.
Methods. Six group interviews were conducted with 17 patients with knee OA. Discussion topics included first
impressions about using colour to describe pain, whether participants could associate their pain with colour,
how colours related to changes to intensity and different pain qualities, and whether they could envisage using colour to describe pain to healthcare professionals.
Results. The group interviews indicated that, although the idea of using colour was generally acceptable, it did
not suit all participants as a way of describing their pain. The majority of participants chose red to describe highintensity pain; the reasons given were because red symbolized inflammation, fire, anger and the stop signal in a
traffic light system. Colours used to describe the absence of pain were chosen because of their association with
positive emotional feelings, such as purity, calmness and happiness. A range of colours was chosen to represent
changes in pain intensity. Aching pain was consistently identified as being associated with colours such as grey or
black, whereas sharp pain was described using a wider selection of colours. The majority of participants thought
that they would be able to use colour to describe their pain to healthcare professionals, although issues around
the interpretability and standardization of colour were raised.
Conclusions. For some patients, using colour to describe their pain experience may be a useful tool to improve
doctor–patient communication. Copyright © 2013 John Wiley & Sons, Ltd.
Keywords
Pain; osteoarthritis; colour; communication
*Correspondence
Vikki Wylde, Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Avon Orthopaedic Centre, Southmead Hospital, Bristol, BS10 5NB, UK. Tel: +44 (0) 117 323 5906; Fax: +44 (0) 117 323 5936.
E-mail: [email protected]
Published online 13 March 2013 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/msc.1048
Background
Osteoarthritis (OA) is one of the leading causes of chronic
pain in Europe and the United States (Breivik et al., 2006;
Hootman and Helmick, 2006). The knee is the joint most
frequently affected by OA, with 10% of all adults over
55 years of age experiencing painful knee OA with
mild–moderate disability (Peat et al., 2001). Research into
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the nature of OA pain has highlighted the existence of two
distinct types of pain: a constant aching pain which is
punctuated by an intermittent and unpredictable pain
(Hawker et al., 2008b). Pain assessment is fundamental
to the management of OA pain and evaluating the effectiveness of clinical interventions. The subjective nature
of pain lends itself to assessment via self-report.
Musculoskelet. Care 12 (2014) 34–46 © 2013 John Wiley & Sons, Ltd.
Wylde et al.
Numerous disease-specific outcome measures that assess
pain have been developed, including the Western Ontario
and McMaster Universities Arthritis Index (WOMAC)
(Bellamy et al., 1988), Intermittent and Constant
Osteoarthritis Pain questionnaire (ICOAP) (Hawker
et al., 2008a) and Osteoarthritis Knee and Hip Quality
of Life questionnaire (OAKHQOL) (Rat et al., 2005).
However, some people can experience difficulties in
completing standardized numeric or descriptive pain
measurement tools because they find it challenging to
explain their pain experience through pre-defined questions and response options (Gooberman-Hill et al.,
2007; Wylde et al., 2012).
The identification and development of alternative
pain assessment methods may address some of the challenges faced by patients, particularly if new methods build
on constructs that are acceptable and meaningful to them.
In clinical settings, the ability to discuss pain in terms that
patients relate to is a key component of successful
communication between patients and clinicians. Therefore, new pain assessment methods may also facilitate
communication and improve shared decision making
about subsequent treatment and management strategies.
Shared decision making is a core component of patientcentred care, and allows patients and clinicians to
understand important preferences and values that inform
decisions, such as whether to choose joint replacement
(Barry and Edgman-Levitan, 2012; Elwyn et al., 2012). A
systematic review of the literature found that more active
patient involvement in decision making can lead to patients
making better informed decisions and opting for more
conservative treatment strategies (Stacey et al., 2011).
An Interdisciplinary Expert Consensus Statement on
the assessment of pain in older people includes recommendations for the use of a colour-based tool in older
adults with intact or impaired cognitive functioning
(Hadjistavropoulos et al., 2007). There has been longstanding interest in colour and health. For example,
there is increasing research and clinical awareness of
Grapheme-colour synaesthesia, in which the perception of numbers and letters is associated with the
experience of colours (Pearce, 2007). Colour has also
been used as a component of art therapy interventions,
which allow people to explore and express their
emotions through the creative process of making art.
Clinical art therapy interventions have been found to
reduce symptoms and psychological distress in oncology
patients (Nainis et al., 2006), patients with AIDS/HIV
(Rao et al., 2009) and patients undergoing bone marrow
Musculoskelet. Care 12 (2014) 34–46 © 2013 John Wiley & Sons, Ltd.
The Colour of Pain
transplant (Gabriel et al., 2001). In addition to using
colour in clinical interventions, there has been an interest
in the application of colour to assessment methods in
health research.
Several colour-based tools have been developed for
the assessment of pain. The Analogic Chromatic
Continuous Scale (Grossi et al., 1983) consists of a colour scale, from light pink (indicating no pain) through
shades of red to black (indicating severe pain). The
Color Analog Scale is a similar scale, developed for
use in a paediatric population, which involves the
respondent sliding a marker along a colour thermometer from light pink (no pain) to deep red (worst pain)
(McGrath et al., 1996). The pictorial Scale of Pain
Intensity consists of a sequence of vertically aligned
red circles, which increase in size to represent increasing pain intensity (Jackson et al., 2006). The
PAULA pain-meter consists of five coloured emoticon faces, with the red-coloured face representing
the worst pain imaginable and the yellow-coloured
face representing no pain (Machata et al., 2009).
The tools described above have been used to assess
pain in a range of settings, such as paediatrics
(Bulloch and Tenenbein, 2002; McConahay et al., 2006),
post-surgical pain (Nayman, 1979; Machata et al., 2009),
burns pain (Gordon et al., 1998), chronic pain (Jackson
et al., 2006) and with nursing home residents (Closs
et al., 2004).
When used in adult populations, colour-based pain
assessment tools have been found to be favoured by
some people over other more conventional tools, such
as the Visual Analogue Scale (Gordon et al., 1998;
Jackson et al., 2006). In spite of this, colour-based tools
are not frequently used in the assessment of OA knee
pain (MacKichan et al., 2008). Therefore, the application of colour-based tools in the assessment of OA
pain warrants further investigation. However, the
currently available colour-based pain assessment
tools described above all use pre-defined colours,
with the underlying assumption that these colours
will be recognized as representing pain by respondents. Before considering the use of these tools, it
is important to explore how individuals with knee
OA would use colour to describe their pain. The aim of
the present qualitative study was to explore views on
the acceptability and feasibility of using colour to
describe osteoarthritic pain, and whether colour could
be used in a clinical setting to communicate about the
pain experience.
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The Colour of Pain
Participants and methods
Recruitment
People with painful knee OA were recruited from an
outpatient physiotherapy department at an elective
orthopaedic centre. Study packs were distributed by a researcher to patients who attended group physiotherapy
sessions. Individuals who were interested in participating
were asked to return a reply slip, and then a member of
the research team contacted them to discuss the study
further, enabling them to ask questions and to discuss
practical arrangements for their participation.
Group interviews
Qualitative group interview methods were chosen as a
means to explore participants’ experiences of OA and
their views about using colour to describe pain. Group
interviews of 2–3 people enabled participants each to
provide their views in turn, but to do so in the context
of some discussion with other participants. These
groups were smaller than would be usual for ‘focus
groups’. Strictly speaking, focus groups are a type of
group interview that harnesses discussion and interaction as a means of generating information (Kitzinger,
1995). By including smaller numbers in each group
than would be usual in focus groups, the study
provided participants with the chance to describe their
individual experiences in more detail than might be
possible in a larger group. However, as an advantage
over one-to-one interviews, the presence of others in
a ‘group interview’ setting meant that participants were
able to interact, discuss the topics and ask each other
for clarification. We describe the data collection
process as ‘group interviews’ rather than ‘focus groups’
(Silverman, 2011).
Groups were stratified by gender, so that participants
attended either a women’s or a men’s group. This
approach is known to encourage open communication
and discussion about sensitive topics, such as pain and
illness (Seale et al., 2006). Each group was led by an
experienced facilitator (R.G.H.) and a scribe was
present to note the first words of each statement
to facilitate the assignment of statements to individual participants and maintain subsequent transcribing accuracy. All participants provided informed,
written consent immediately before the session
started and group interviews lasted two hours each,
including a brief rest break. Participants were
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Wylde et al.
reimbursed for their travel expenses, and light
refreshments were provided.
Sessions started with participants’ individual completion of a questionnaire booklet about age, gender,
duration of knee pain and a body diagram of pain locations. Participants were also asked to provide ratings of
the severity of their knee pain on a Visual Analogue
Scale, Numerical Rating Scale and Likert-type scale.
As participants worked through the booklet, the facilitator asked how they found the questions and asked
them to elaborate, verbally, about their answers. This
provided background information, after which participants were asked to talk about living with OA, their
experience of pain and their preferred management
strategies. The discussion then moved on to participants’ first impressions and opinions about using
colour to describe pain, grounded in their own experiences and in advance of placing any colours in front of
them. For instance, the facilitator asked, ‘have you ever
thought about pain as having a colour?’ and, ‘thinking
back to a time when you had pain, can you think of that
pain as having a colour?’ The facilitator used a topic guide
(Table 1) to assist in the formulation of questions, but
precise wording was tailored to participants to match
their own vocabulary. The facilitator also probed the
answers given by participants, asking them to explain
and expand where possible.
Groups then stopped for a brief comfort break, after
which the facilitator placed ten loose circles of doublesided, laminated coloured card within reach in the
centre of the table around which the group sat. Colours
were chosen to represent colours as ‘pure’ as possible
(Eysenck, 1941); all were PantoneW colours, and each
circle was approximately 21cm in diameter, to facilitate
handling. To ease discussion, the facilitator asked
participants to agree between them the names for the
colours; these were agreed as: purple (Pantone 2593c),
yellow (Pantone 102c), orange (Pantone 164c), red
(Pantone 186c), brown (Pantone 1405c), white (no
Pantone reference), black (Pantone Black c), grey
(Pantone 402c), green (Pantone 347c) and blue (Pantone
293c). She then asked participants to think about whether
they could relate any of the coloured circles to their OA
pain and, if so, how those colours related to changes in
pain intensity and different pain qualities. Participants
were encouraged to handle the coloured circles and to arrange them to reflect intensity as they saw fit. After this
discussion, participants used coloured pencils to depict
their pain on a diagram of lower limbs. The facilitator
Musculoskelet. Care 12 (2014) 34–46 © 2013 John Wiley & Sons, Ltd.
Wylde et al.
The Colour of Pain
Table 1. Topic guide for the group interviews
Knee pain (including completion of questionnaire booklet about age,
gender, duration of knee pain, body diagram of pain locations, pain
severity)
Living with osteoarthritis and preferred management strategies
First impressions and opinions of using colour to describe pain
Colour and knee pain (including completion of colouring exercise)
Communication and colour
then asked them to discuss the colours that they had
chosen and how these related to their pain. Group
interview sessions concluded with questions about
whether participants felt that they or others would be
able to use colour to describe pain to healthcare
professionals (HCPs).
Can you describe where you have marked as painful on the body
diagram?
Can you describe what your knee pain feels like?
Does it vary over the day?
How does it feel at night?
Does it vary with different activities?
Does your knee pain stop you from doing things that you would like to
do? What kinds of things do you do to ease your knee pain?
(physiotherapy, medication, exercise, rest, heat/cold, dietary
supplements)
Thinking about any times you have had pain in your life, have you ever
thought about pain as having a colour?
What colour/s would that be?
Did you think of that at the time?
Introduce and agree on names of the circles of coloured card
Do different types of pain have different colours?
Do different pain intensities have different colours?
Does no pain have a colour?
Do different colours make you think about different emotional feelings?
Does stiffness have a colour?
If you can’t use colour to describe pain, what does work as a way of
describing your knee pain?
What colours have you used on the body diagram? How do these colours
relate to pain?
Can you imagine using colour to talk about your pain with healthcare
professionals, such as doctors, surgeons, nurses or physiotherapists?
sessions; for instance, in later sessions the facilitator
asked directly about colours for stiffness and emotions,
as these were spontaneously mentioned by participants
in the first sessions. Such iteration is a normal feature
of qualitative methods (Gooberman-Hill, 2012) .
Ethics approval
Analysis
Each group interview was audio-recorded, fully transcribed and the transcripts were anonymized with
pseudonyms. Transcripts were imported into NVivo©
version 9(QSR International; http://www.qsrinternational.com/products_nvivo.aspx) and analysed using
methods of constant comparison (Glaser and Strauss,
1967). Provisional inductive coding of two transcripts
was independently conducted by all members of the
research team. These provisional codes were then
discussed in the team to reach consensus over the overall
code list and grouping of codes. Codes were modified
and refined through analysis of further transcripts and
revisiting earlier ones. The codes were then grouped into
themes based on similarities in content. Analysis of early
group sessions was used to inform the content of later
Musculoskelet. Care 12 (2014) 34–46 © 2013 John Wiley & Sons, Ltd.
Ethics approval was obtained from the NHS South West 3
Research Ethics Committee (reference 10/H0106/54) and
all participants provided informed, written consent.
Results
Study packs were given to 93 people during group
physiotherapy sessions and 17 people participated in
the study. Six group interviews were conducted: five
groups with three participants and one group with
two participants. The groups were stratified by gender,
with three female groups and three male groups. All
participants were British and the mean age of participants was 74 years (range 62–85 years). Details on
participant demographics, pain severity ratings and
other painful joints are displayed in Table 2. With this
number of groups and participants, we believe that data
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Wylde et al.
The Colour of Pain
Table 2. Participant details
Group and
pseudonym
Group 1:
Mrs A
Mrs B
Mrs C
Group 2:
Mr D
Mr E
Mr F
Group 3:
Mrs G
Mrs H
Mrs I
Group 4:
Mr J
Mr K
Mr L
Group 5:
Mrs M
Mrs N
Mrs O
Group 6:
Mr P
Mr Q
Age (years)
Duration
of knee pain
VAS
NRS
Likert-type scale
Painful joints
Previous joint
replacements
71
79
80
5 years
2 years
1 year
84
23
72
9
4
7
Moderate–severe
Moderate
Severe
Neck, back, hands, knees
Shoulder, back, knee
Hands, hips, knees
THR
67
85
62
1.5 years
5 years
14 years
25
36
64
2
4
7
Mild
Moderate
Severe
Hip, knee
Knees
Knee
UKR
72
67
77
4 years
1 years
1.5 years
39
20
54
6
3
7
None, mild, extreme
Moderate
Moderate–severe
Shoulders, knees
Shoulder, elbow, hand, hip, knee
Back, knees
72
68
80
6 years
2 years
1 years
37
36
15
8
4
1
Moderate
Mild
Mild
Hand, knee
Shoulder, thumbs, knees
Back, knee, foot
70
75
73
8 years
4 months
1 year
75
77
32
7
8
2
Moderate–severe
Moderate–severe
Mild
Both knees, hip, neck, back
Knee
Both knees
83
70
1.5 years
3 years
57
24
4
2
Moderate
Mild
Knee, hand
Knee, hip, neck, hand
Female
Male
Female
Male
Female
TKR
Male
NRS, Numerical Rating Scale; THR, total hip replacement; TKR, total knee replacement; UKR, unicompartmental knee replacement; VAS, Visual
Analogue Scale.
saturation was achieved, as in later interviews discussion and themes echoed those that had already
emerged. However, it is worth noting that the study
aimed to explore whether colour could be used to
discuss OA pain and, if so, how people with OA described
those connections. As such, the study did not aim to explore gender, cultural or ethnic differences. As discussed
later, future studies could work towards this, especially
in light of known cultural variation in colour symbolism.
Emergent themes are described below, using participant
quotations to illustrate key points (Table 3). An overview
of colours chosen by participants to describe their OA
pain is provided in Table 4.
Participants’ views about using colour to
describing pain
Initial reactions to the concept of using colour to describe
any kind of pain included the sense that the idea was
novel to participants, most of whom had not previously
considered thinking about their pain in terms of colour.
One participant (Mr K) had previously related his pain
to the colour red, although he said that he did not know
38
why he perceived pain in this way. In spite of some initial
concerns about inability to relate their pain to colour, all
participants except one (Mr L) used colour to describe
their OA pain during the interviews. However, even as
the groups progressed, the ease with which participants
could relate their OA pain to colour varied, with some
participants finding it easy to do but with others experiencing difficulty. By the end of the interviews, some participants who initially could not easily associate pain with
colour had become engaged with the idea of using
colour. One participant (Mrs H) discussed the advantages of using colour over more conventional pain assessment methods, such as numbers, explaining that
she thought that colour was more suited because of
the many shades of colour. However, other participants said that they remained unlikely to associate
colour with pain and would not use it to talk about
their pain in the future. One participant (Mrs N)
preferred to use words rather than colour to
describe her pain, explaining that this may have been
because she was not an ‘arty’ person. The group interviews showed that although the idea of using colour was
generally acceptable, it did not suit all participants.
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Table 3. Participant quotations
Themes and quotations
Participants’ views about using colour to describe pain
Novel idea
R.G.H.: What about you, Mr F, have you ever thought about that pain as having a colour?
Mr F: No I can’t really honestly say I’ve related it [colour] to pain.
R.G.H.: Mrs N, have you got any thoughts on colour?
Mrs N: No I’ve never really thought of it [pain] associated with colour.
Mrs C: How does it [pain] relate to colour? You know, I mean it’s a completely new thing isn’t it?
Previous associations of colour to pain
R.G.H.: I’m wondering if any of you have ever thought about any of the pain that you’ve ever experienced – whether that’s knee pain or something else in
your life that’s been painful in the past – have you ever thought about pain as having colour?
Mr K: Well, the only thing I can say is, when I get like this very sharp pain, I immediately think red. Now I don’t know why.
R.G.H.: OK, but red comes to mind?
Mr K: I don’t see red, or anything like that, but it’s just this, I think, “Ow”, you know, and red. I don’t know why.
Ease of relating colour to pain
R.G.H.: How did you find it to do the pencil drawing, thinking about your pain in this way?
Mrs B: Well I think before the discussion I would have found it difficult. But since we’ve been talking colour and things, I just found it quite – quite
easy to do.
R.G.H.: Mr J, do you think you could use colours?
Mr J: Yeah I could. But, um, this is a new thing for me, colours. Colours are brilliant.
Mr E: But, um, you know, so it’s, um – I find it very, very difficult to use colours to describe pain.
Advantages of using colour to describe pain
Mrs H: Um, well, you know, I think, um, you could say 5–6, or maybe 5½, you know, but I think with colour you’ve got so many more shades than you
have with numbers. . .I think it’s graduated better with the colours than with numbers. Because I mean like you could say 1–100, couldn’t you? And it
wouldn’t be – I don’t think it would be the same. But I think, um, I can associate more with.
Mrs G: with colours, yes.
Mrs H: with colours.
Reasons for not using colour to describe pain
R.G.H.: What do you think, Mrs N, do you think you’d use colour to talk about pain?
Mrs N: No I’d rather use words, you know, ouch or something like that. . . Maybe because I’m not an arty person. So, you know, it would mean a lot more
to somebody who enjoys art.
High-intensity pain
Mr F: I suppose, ultimately, that’s got to be severe because red seems to be a challenging sort of, um, thing, sort of thing. So, you see red, don’t you, when
you’re either cross, angry or in pain, or, allegedly, um, sort of thing, or in all the fictitious books that I read anyway.
R.G.H.: And red, what is it about red that makes you think about pain?
Mr P: Well, because every time you cut yourself or you bend something, it gets inflamed and goes red, and therefore that’s pain.
R.G.H.: And for you, what is it about red that makes it related to pain?
Mr Q: I don’t know, really, I don’t know. I’d sort of previously thought about that in terms of maybe on a sort of traffic light system.
Absence of pain
Mrs B: If it’s white there’s no feeling, there’s no anything, pure. And then suddenly you start coming to the colours.
Mr J: No pain, then I’d have to go for the orange. . . orange is my lovely colour. . . I feel happy with orange.
Mrs N: Yes and for days with no pain I’d pick yellow. . .and, um, yellow is a bright colour and, er, pleasant days of sunshine.
(Continues)
Musculoskelet. Care 12 (2014) 34–46 © 2013 John Wiley & Sons, Ltd.
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Wylde et al.
The Colour of Pain
Table 3. (Continued)
Themes and quotations
Participants’ views about using colour to describe pain
Changes in pain severity
Mrs B: Yeah, if you sense pain then you see the reds and blues, and when the pain is easing off you can see the beiges and the yellows and the whites,
can’t you?
Mr E: Actually, if you asked me that, I would reduce the colours to traffic lights.
Mr K: Yes, well, red would obviously be my extreme one. Um, I think I would probably put them in, in that sort of order: red, white and yellow.
Pain qualities
Aching pain
Mr D: Um, right-side view, it’s the same sort of thing, the patella is knocking about and being a bit achy, and I’ve described the grey as more of an ache
pain as opposed to a real pain.
Mrs M: And black I would pick for continuous nagging grey pains.
Mrs N: Um, well, as it’s sort of a dull ache, grey to me. You know, it’s not quite bad enough to be black.
Sharp pain
Mr D: A sharp, catch-you-out type of pain. And red and yellow are sort of flame aren’t they?. . . And that’s why, you know, “Ah”, like somebody had put
a knife there or something, a knife or a sharp thing, but some heat or some burst of pain.
Mrs H: It’s very sharp and I think of white, something white hot.
Mrs M: Yellow I would pick for shooting pains. . . I said like lightning, and that’s sort of yellow isn’t it?
Mrs N: And the sharp pain, I’d go for purple. . . And purple is something that you see and – and notice more, I think, there.
Stiffness
Mrs I: Well, oddly enough, I mean I think that when it’s stiff would. . .
R.G.H.: The purple?
Mrs H: Yes, yeah, I think purple.
Mrs I: I was thinking that, I thought of orange more than purple.
Mrs H: It’s a different type of pain. This is the other thing, you get different types of pain.
Mrs N: Perhaps that’s where the brown comes in.
R.G.H.: OK, this one?[points to the brown-coloured circle]
Mrs N: Hmm. Dullness.
Mrs M: I’d go with the grey.
R.G.H.: Yeah, for stiff?
Mrs M: Yeah. Because it’s not only stiffness, it’s painful as well.
Using colour to describe pain to healthcare professionals
Able to use colour to describe pain to healthcare professionals
R.G.H.: Mrs G, do you think you could talk to the doctors or nurses or physios using colour?
Mrs G: Yeah, yeah, I’d prefer to. . . More than the 1–10 yeah.
Mr J: Yeah. No, I could talk to my doctor about that easy.
Unable to use colour to describe pain to healthcare professionals
R.G.H.: And the question I’d like to put to you all is whether you think it would be possible for you to use colour to talk about pain with doctors or
physiotherapists, do you think that would be a possibility?
(Continues)
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The Colour of Pain
Table 3. (Continued)
Themes and quotations
Participants’ views about using colour to describe pain
Mr L: Well, I don’t think so, to be honest. Um, I think if you said at the start, “Use red when it hurts and use yellow when it doesn’t”, I think that’s
another matter. But, er, to associate – unlike Mr K, I can’t associate colours with the actual pain, really.
Anticipated problems with using colour to describe pain to healthcare professionals
Mr E: I wouldn’t be at all surprised if the actual bloke who is actually doing the surgery or treating you doesn’t take a blind bit of notice of that and says,
“Moderate, very moderate or not”, he looks at the ruddy X-ray and says, “I want something done about it”.
Mr K: Yeah, yeah, that was – that was my thought on it, was, you know, if you’re going to talk to the doctor about it, if you haven’t got a standard sort of
range, if you just say to the doctor, “Oh, you know, pale green”, something like that, it’s – it’s – what’s it going to mean to him?
Mr J: Would the doctors understand?
Need for information
Mrs A: But would they [healthcare professionals] know what you were talking about?. . . I think if they had the same instructions as what you’ve got, yeah,
they would have to go on seminars, wouldn’t they? Um, yeah, they would. But otherwise I don’t think my doctor would have a clue.
Standardized colour chart
Mrs B: But if he was told that these colours relate to this amount of pain, and then you go in to him and you say, “My pain is red”, and he looks up on his
chart that he’s got there, that’s the degree of pain that you’re experiencing, I suppose then it would be helpful.
Mrs G: Yeah, it has to be uniform, like the lights on the road, whether to have them green, it has to be uniform, yeah, because otherwise you’re green, we’re
blue over here.
Mrs H: Yes, if you said to me before this, “My pain is green”, I would think, well, green’s not on my chart at all [laughs], you see. So, I wouldn’t really know what
you were talking about. And that’s what bothers me, you know, with a doctor or a nurse or a physio.
Mr L: I think you’ve got to have a standard set so that – and I’m sure, if we’d come in here this morning and you’d said, “Instead of the 1–10, those are the
colours”, I would think we’d all be able to use that just as easily as we use the numbers.
Mr K: I mean that, you know, something like that, a standard chart, wouldn’t work though, would it? Because it would be no different than the numbers,
would it, I guess?. . . For someone to give me a chart and say to me that, well, say for argument’s sake, that green or black or something is the worst pain, I
would find that difficult.
High intensity pain
Changes in pain severity
The majority of participants used red to describe
their most intense pain. Diverse reasons were given
for choosing red, including symbolization of inflammation, fire, moods such as anger, and the stop
signal in a traffic light system. Although red was the
most commonly used colour to describe intense
pain, other colours were used by some participants,
and these colours included white, blue, grey and
black (Table 4).
All except three participants selected a range of colours
to represent changes in pain intensity from no pain to
high intensity pain. All colours, except brown, represented by the discs were used by one or more participants
to describe changes in pain intensity. The colours used to
describe different pain intensities were diverse and individual, with no patterns emerging as to the colours used,
except for those participants who chose the colours of a
traffic light system (Table 4).
Absence of pain
Pain qualities
Participants described the absence of pain with a range
of colours – namely, white, yellow, orange, blue and
green. These colours were often chosen to represent
no pain because of their association with positive emotional feelings or experiences, such as purity, calmness,
peacefulness, happiness or sunshine.
Participants used different colours to describe the two
types of pain normally characteristic of OA: an aching
pain and an intermittent, unpredictable sharp pain.
When describing aching pain, participants consistently
identified neutral colours such as grey or black. In
comparison, intermittent and unpredictable sharp pain
Musculoskelet. Care 12 (2014) 34–46 © 2013 John Wiley & Sons, Ltd.
41
Wylde et al.
The Colour of Pain
Table 4. Overview of colours chosen by participants to describe pain
Pseudonym
Colours chosen to describe pain
(from highest intensity pain to no pain)
Pain qualities
Mrs A
Mrs B
Mrs C
Mr D
Red, orange, green grey, yellow
Blue, red, grey, yellow, orange, white
Red, purple, grey, (no colour chosen for no pain)
Red, orange, green
Mr E
Mr F
Red, orange, green
Red, grey, green
Mrs G
Mrs H
Red, blue
White, red, yellow, blue
Mrs I
Mr J
Red, orange, green
Grey, orange
Mr K
Mrs M
Red, green, white, yellow
Black, blue
Mrs N
Grey, blue, yellow
Mrs O
Grey/black, white, green
Mr P
Mr Q
Red, orange, white
Red, grey, orange, yellow, green
Burning pain – red
Bone pain – green
Aching pain – grey
Sharp pain – yellow/red
Aching pain – grey
No colours chosen
Sharp pain – yellow
Intermittent niggling pain – grey
Constant pain – red
No colours chosen
Sharp pain – white
Stiffness – purple
Stiffness – orange
Aching pain – grey
Stiffness – grey
Sharp pain – red
Shooting pain – yellow
Continuous pain – black
Stiffness – grey
Sharp pain – purple
Aching pain – grey
Stiffness – brown
Constant pain – black/grey
Sharp pain – red
Sudden pain – red
Stiffness – grey
Sudden pain – red
Mr L is not represented in the Table as he could not use colour to describe his pain
was described using a wider range of colours, including
yellow, white, red and purple. Participants often described
this unpredictable sharp pain as the most painful of their
OA sensations, and some used the same colours to
describe it as they chose for their highest intensity pain.
Reasons given for choosing these colours included heat,
sharp or knife-like pain and lightening. Stiffness was also
described using a range of colours, including brown, grey,
purple and orange. These findings provide further
evidence for the existence of distinct and different pain
qualities in OA, and that colours are chosen because of
their association with metaphors for sensations.
communication method that they were familiar with.
They thought that this could be mitigated by providing
HCPs with information and perhaps a standardized
colour chart, although this was not seen as straightforward. These discussions around the use of colour to
describe pain to HCPs raised important issues around
the interpretability of colour. Participants discussed
the need for a standardized colour chart to facilitate
the interpretation of colours and pain, but also considered the associated difficulties accompanying this in the
face of individual variability.
Discussion
Using colour to describe pain to HCPs
Although the majority of participants thought that they
would be able to use colour to describe their pain to
HCPs, they also discussed the potential challenges of
doing so. For instance, they suggested that HCPs would
find colour difficult to understand if it was not a
42
The present study explored whether people living with
painful knee OA could use colour to describe their pain
and, if so, in what ways. Few participants had previously thought about or used colour to describe their
pain, but all except one felt that they could do so.
However, some people found it easier than others to
Musculoskelet. Care 12 (2014) 34–46 © 2013 John Wiley & Sons, Ltd.
Wylde et al.
describe their pain in colour. This suggests that, although
the idea of using colour was generally acceptable, it does
not suit all individuals.
Red was the colour that was most frequently chosen
by participants to describe high intensity pain, although
a number of other colours were also used. The majority
of existing validated colour-based tools depict severe
pain with red (McGrath et al., 1996; Jackson et al.,
2006; Machata et al., 2009) either because red has been
found to be associated with high intensity pain (Machata
et al., 2009) or because of the strong visual impact of red
and its intuitive association with pain (McGrath et al.,
1996; Jackson et al., 2006). Although not all participants
could verbalize reasons for their choice of colour, some
chose red because they saw it as symbolizing inflammation, fire, moods such as anger, and and the stop signal
in a traffic light system. This resonates with the culturally
specific emotive nature of red (Clarke and Costall, 2008),
which has many negative associations in Western culture,
including blood, fire, anger, violence and brutality
(O’Connor, 2011). Red is encountered on a daily basis
as a symbol of danger or emergency, such as at road traffic
lights. Therefore, the choice of red by many participants
to represent high intensity pain is not entirely surprising.
However, some participants chose other colours, such as
white, blue, grey and black, suggesting that there is some
diversity in the colours chosen to represent high-intensity
pain. In comparison, the colours used to represent the
absence of pain, changes in pain intensity and different
pain qualities were diverse and individual, often chosen
for their association with positive emotional feelings or
as metaphors for sensations.
Colour-based tools have been found to be useful
pain assessment methods in particular contexts, such
as with children, people with dementia or communication impairments, or in an acute post-surgical
setting (Nayman, 1979; Jackson et al., 2006; McConahay
et al., 2006; Machata et al., 2009). However, in light of the
individual variability in the colours chosen to represent
the different types and intensities of OA knee pain,
the shades of red used in many tools may be an
oversimplification for the assessment of chronic knee
pain. Furthermore, the complexity of the data generated from the present study suggests that, although
colour could be a useful pain assessment tool, further
research is required to explore the difficulties
envisaged by participants in the representation,
standardization and interpretation of colour-based
descriptions of pain.
Musculoskelet. Care 12 (2014) 34–46 © 2013 John Wiley & Sons, Ltd.
The Colour of Pain
It is important to acknowledge some of the limitations of this research when interpreting the results.
The recruitment rate was low, and, as patients were
approached about the study during group physiotherapy sessions, it was not possible to collect demographic
data on non-respondents; this meant that participants
and non-participants could not be compared. The
number of participants in the study was small, and it
is possible that these individuals participated because
they had a particular interest in the topic of colour,
which was introduced in the information material, in
keeping with the need to ensure informed consent to
participation. However, the nature of the research was
not to produce findings which were representative of
a wider population (Cohen and Crabtree, 2008), but
to use qualitative methods to gain in-depth insight into
people’s thoughts and opinions about the use of colour
to describe pain. Group interviews were chosen over
individual interviews because the group interaction
facilitated exploration and clarification of views in the
context of discussion. Although the views of some participants may have been influenced by others in the
groups, the format enabled participants to ask one
another for clarification and elaboration. This discursive aspect of the group interviews provided the opportunity to express and develop ideas that participants
might not have previously had the chance to verbalize.
It is also necessary to consider other important factors
which could influence the way that people use colour
to describe pain that were not explored in the present
study. It is important to acknowledge that colour is
imbued with meanings that are culturally specific
(Schirillo, 2001). For instance, whereas red is often a
sign of danger in Western culture, it is traditionally
the symbolic colour of happiness and good luck in
China (Hurlbert and Ling, 2007). The sample in the
present study was not ethnically or culturally diverse
and future research could explore cultural variation in
the association of pain with colour. In addition, previous research has found that men and women talk
differently about pain (Gooberman-Hill et al., 2009).
The group interviews in the present study were stratified by gender for data collection purposes, rather than
to explore gender differences. The small number of
men and women would have made it inappropriate to
analyse gender differences, and, although men were
more likely to employ the ‘traffic light’ analogy, we
identified no gender differences in receptivity to the
use of colour to describe pain. With only one
43
Wylde et al.
The Colour of Pain
participant finding it impossible to think about pain in
terms of colour, further research would need to address
any gender differences.
An interesting finding from the present study was
that the use of colour initiated rich descriptions and
discussions of different aspects of the pain experience,
which are evidenced in Table 3. Qualitative research
has previously found that the use of standard questionnaire items within interviews can stimulate narratives
about the experience of health and illness, by providing
a way into opening up discussions on sensitive issues
(Adamson et al., 2004). Visual representations of pain,
such as photographs and drawings, have also been
found to improve communication between clinicians
and patients (Maclean, 2009; Padfield et al., 2010).
Successful communication between clinicians and
patients is central to shared decision making about
the treatment and management of long-term conditions (Politi and Street, 2011). Perceived inability to
communicate or express pain successfully can have detrimental effects, such as reducing symptom management, coping strategies, psychological well-being and
physical functioning (Thorne et al., 2005). In the group
interviews, the use of colour stimulated discussion and
provided an alternative means of communicating information about pain.
Pain is inherently subjective and some people can face
difficulties in expressing their pain, particularly in a clinical
setting (Miller et al., 1994). Previous research has found
that, in a clinical setting, enquiries about pain can often
have a closed question format (Rogers and Todd, 2000;
Berry et al., 2003). Providing patients with the opportunity
to describe their symptoms in response to an open-ended
question can lead to greater satisfaction with the consultation (Robinson and Heritage, 2006). Presenting patients
with a range of colours and asking them how they would
use them to describe their pain may be a useful tool to
improve doctor–patient communication in an appropriate clinical setting by eliciting descriptions of the pain
experience. As evident from the present study, this would
not be a tool for everyone but, for some people, engagement with colour may provide a comfortable way to
initiate discussions around pain. Further research would
be required to explore the format and presentation of a
colour-based communication tool, and whether its
application in a clinical setting could encourage
doctor–patient discussions around pain, overcoming
barriers to communication and facilitating shared
decision making.
44
Conclusion
The present study, involving group interviews with
patients with knee OA, found that, for some patients,
using colour to describe their pain experience may be a
useful tool to improve doctor–patient communication.
Acknowledgements
The research team would like to thank Ian Learmonth
for his support and valuable insight throughout the
study and Catharine Elliot for transcribing the
audio-recordings. We also thank the patients who
participated in the study and the physiotherapists
who permitted the research team to introduce the
study to patients at group physiotherapy sessions.
This study was funded through internal Department
funds.
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