The Mankoski Pain Scale

I searched far and wide for a pain scale that made sense to me and ended up with the Mankoski Pain Scale which was developed for Endometriosis sufferers. I finally had language to go with the numbers, and a tool I could hand a provider if they weren’t sure what I was talking about.

However, the Mankoski Pain Scale seems to be disappearing from the internet so I thought I would post it here. For instance the original links I used in 2012 are all dead, including the ones that discussed the development of the scale. Chronically Awesome1 has a version on Scribd2, but I like the original better and will explain why along with some tips on communicating pain to health care providers at the end.

The Mankoski Pain Scale

Pain Free No medication needed.
Very minor annoyance – occasional minor twinges. No medication needed.
Minor annoyance – occasional strong twinges. No medication needed.
Annoying enough to be distracting Mild painkillers are effective. (Aspirin,
Can be ignored if you are really involved
in your work, but still distracting.
Mild painkillers relieve pain for 3-4 hours.
Can’t be ignored for more than 30 minutes. Mild painkillers reduce pain for 3-4 hours.
Can’t be ignored for any length of time, but you can still go to work and participate in social activities. Stronger painkillers (Codeine, Vicodin) reduce pain for 3-4 hours.
Makes it difficult to concentrate, interferes with sleep You can still function with effort. Stronger painkillers are only partially effective.
Strongest painkillers relieve pain (Oxycontin, Morphine)
Physical activity severely limited. You can read and converse with effort. Nausea and dizziness set in as factors of pain. Stronger painkillers are minimally effective.
Strongest painkillers reduce pain for 3-4 hours.
Unable to speak. Crying out or moaning uncontrollably near delirium. Strongest painkillers are only partially effective.
Unconscious. Pain makes you pass out. Strongest painkillers are only partially effective.

Sourced From:

Above is the original scale (from what I can tell) that was developed by Andrea Mankoski in 1995.

It is important that pain levels are not grouped together, or colored. Our eyes are drawn to that and are likely when we are hurting to go for “Danger! Danger!”. There is also no description directly under the number. This leads the eye to look at the descriptions first and the number second.

Also, it is so important that the description of that particular pain level, and the medication response are grouped separately. The why of this fits into how to communicate your pain to healthcare providers.

Downloads of the Mankoski Pain Scale:

Tracking Your Pain

I recommend rating pain before an intervention such as taking pain medication. Then based on the response to the pain medication assess whether or not that initial pain rating was accurate. It is ok to change it.


  • I’m having severe lower back, pelvic, hip, and leg pain. It is extremely hard for me to concentrate and I can’t filter it out so I rate it as an 8.
  • I take my Hydrocodone for the pain and after an hour it rates as a 4.
  • Based on my treatment response I overrated with my initial pain assessment. My pain was more likely a 7 on the pain scale since mid-grade narcotic pain killers had a significant but not total impact.

Another complicating factor in rating pain is that when we are thinking about pain we of course feel it more intensely. It can be helpful when we identify that we are in pain to attempt to engage in some appropriate activity for a period of time. Whether or not it is possible to concentrate on that activity and to what degree pain is felt during that activity says a lot about the degree of pain.

If it is possible to reduce pain through involvement in any sort of activity it is important to do just that. Even if it is just watching a movie, or listening to music. Pain is a stimulus, if it is the only stimulus of course more attention and focus is going to go towards it.

It is also important to track medication response, the degree to which a given medication helps is important information for you and your provider.

The Don’ts of Communicating Pain to Healthcare Providers

  • If you can say that you’re in 10 level pain, you’re not a 10.
  • If you can describe your pain with even a short sentence you are not a 9.
  • If your voice isn’t strained and you’re not periodically moaning you are not an 8.

The points above are the realities of how providers view pain, one of the biggest problems with pain and healthcare is observations on how providers evaluate pain is not shared with patients. What is communicated to patients is that pain is purely subjective, however, providers look at more than patient report when evaluating pain.

High levels of pain can actually have an impact on vitals, as well as mental status. Providers are also primarily concerned with how pain impacts functioning. So when a patient is sitting up and able to clearly converse and states their pain is a 10 doctor’s are skeptical.

This is a huge flaw in medicine and points out the difference in how medicine and patients define pain. What we as patients need to advocate for is more education on how the field of medicine looks at and evaluates pain. Medicine itself also lacks consensus on the topic. A doctor who treats burn survivors may look at pain very differently than a doctor who primarily treats chronic pain.

We as patients must navigate this quagmire and advocate for well defined standards for evaluating pain. However, we can improve communication with our providers by being specific in how we describe our pain, as well as reserving the 9s and 10s for when pain is completely incapacitating.


The Do’s of Communicating Pain to Healthcare Professionals

  • Have a clearly defined pain scale which you use on a consistent basis, and bring a copy with you.
  • Be descriptive as to what you mean when your pain is a certain number.
  • Describe the type and location of each type of pain.
  • Be clear on how the pain has an adverse effect on your overall functioning. Example: can’t sleep, can’t concentrate, etc.
  • Be clear on how much and how your pain changes based on different types of interventions. Example: OTC pain relievers, narcotics, heating pads, etc. Also include the impact of mindfulness practices, and distraction techniques.

Pain is one of the trickiest things in healthcare to treat because pain is largely subjective. The clearer pain information is presented to a doctor the more likely they are to help you. Also if the patient appears to be a reliable historian (not exaggerating and has clearly organized info) the more likely it is that the doctor is going to feel comfortable treating the pain.

Downloads of the Mankoski Pain Scale:


  1. Meenakshi bisht

    January 22, 2016

    Respected sir i am Student researcher, doing M.Sc nursing from Teerthanker mahaveer college of nursing, india . For my study i am using this mankoski pain scale for that i need your permision to use your pain scale for my research..
    Please answer me as soon as posible….

    • Nezu

      July 16, 2017

      Hi. I’m the author of the Mankoski Pain Scale, and I wanted to say thank you so much for your beautiful, cogent analysis! I’d always been a little worried about my use of medication effects as a metric, because of course people can develop tolerance over time if they are taking narcotics on a regular basis, and some medications work better for some people than others. Your analysis gives me more confidence in having used that metric despite that.

      You’re spot on on all points about how to use the scale to communicate (and not communicate) with your medical care team.

      I wrote the scale to facilitate communication in specific but neutral terms, because the other scales I encountered were either needlessly abstract (numbers without meaning), or overly emotional (pain described with loaded words like agonizing, sickening, etc).

      Even though I am finally free from endometriosis for the most part (thanks to hysterectomy and gender transition), I still use the scale all the time, for every kind of pain. I’m so, so glad it’s still in use.

      For Meenakshi bisht, sorry, this probably comes terribly late, but I released the pain scale under the creative commons license: free to use and reproduce without alteration and with credit to the original author (me.)

      Nezu, formerly Andrea Mankoski

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