Assessment of Pain

Pain Mechanisms – Review

Should drive ALL clinical decisions, tests and interventions

Pain Mechanisms

Step 1 - Screening Tools

• Screen for Red Flags

  • – Review of systems

  • – Medical intake form

  • – Review of medical record

• Is the patient appropriate for PT?
OR
• Referral to another medical provider

Patient Safety

• Demographic info
• Insurance info
• Medical intake form
• Review of systems
• Pain Rating (VAS, Numeric)

• Fear Avoidance
– Fear Avoidance Belief Questionnaire
– Tamps Scale of Kinesiophobia
• Depression - PHQ
• Pain Catastrophizing Scale

Patient Screening

what are screening tools - pain scales?

• face pain scale 

• numerical pain rating scale (NPRS) 

• visual analog scale (VAS) 

• McGill Pain Questionnaire

• Central Sensitization Inventory (CSI)

– For use in children

Face Pain Scale

Numerical Pain Rating Scale (NPRS)

Screening Tools – Pain Scales

• Visual Analog Scale (VAS)
• Ruler to measure the distance in mm on a 10 cm line (0-100)
• Patients place mark on ruler
– 0-4 mm = no pain
– 5-44 mm = mild pain
– 45-74 = moderate pain
– 75-100 = severe pain

Screening Tools – Pain Scales

– Most frequently used multidimensional tool
– Sensory Intensity
– Emotional Impact
– Cognitive evaluation of pain

McGill Pain Questionnaire

– 25 questions
– Score 0-100
– Score > 40 indicates central sensitization (nociplastic pain)

Central Sensitization Inventory (CSI)

what are screening tools - psychosocial assessment?

• Fear avoidance beliefs questionnaire (FABQ) 

• tampa scale of kinesiophobia (TSK) 

• pain catastrophizing scale (PCS) 

• patient health questionnaire (PHQ) 

• StarTBACK

what is fear avoid ance beliefs questionnaire (FABQ)

– 16 items
– Includes physical activity (FABQ- PA) and work (FABQ-W) subscales
– FABQ-PA > 15 indicates fear avoidance
– FABQ-W > 34 indicates fear avoidance

what is Tampa Scale of Kinesiophobia (TSK)?

– Fear of physical activity or movement
– 17 items
– Score 17-68
– Higher scores indicate greater fear of movement and/or reinjury

what is Pain Catastrophizing Scale (PCS)?

– 13 items
– 3 dimensions
• Rumination
• Magnification
• Hopelessness
– Score > 30/52 indicates catastrophizing in relation to pain

what is patient health questionnaire (PHQ) ?

– Depression scale
– PHQ-9
• 0-4 = no to minimal depression
• 5-9 = mild depression
• 10-14 = moderate depression
• 15-19 = moderately severe depression
• 20-27 = severe depression

what is STarTBACK?

– 9 items
– Identifies patients who may be at risk for chronic low back pain
– Separates individuals into low and medium risk categories
– Distress subscale separates the medium risk subgroup into medium and high risk

Step 2 - Subjective Exam

what are types of subjective exams?

• goal establish

• S.I.N.S.S

what is goal establish

– Diagnosis
– Prognosis
– Screening for red flags
– Set PT/pt goals
– POC
– Treatment interventions
– Therapeutic Alliance
– Symptom of severity and irritability

what is S.I.N.S.S

– Severity
– Irritability
– Nature
– Stage
– Stability

what are types of Subjective Exam – Communication?

• verbal 

• non-verbal 

what is verbal communication?

– “Words the hurt and words that heal”
• “torn” “wear and tear” “ riped” “herniated” “congestive heart failure”
– Repeated pain rating
– Reassurance
• “You are going to be ok”

what is non-verbal communication?

– Physical signs of pain
• Grimace
• Stern look
• Dilated pupils
• Sweating
• Fast and shallow breathing
• Moving away from pain
• Unloading painful side
• Neglect

• Open Ended Questions
• Be receptive, open, and attentive
• Guide the Interview
• Speak clearly and slowly

Communication - Motivational Interviewing

Subjective Exam – 5 Areas

• Typical reasons for seeing a PT may include
– Pain
– limited movement
– range of motion
– Weakness
– Numbness
– decreased function
– fall risk
– etc

Type Of Disorder

categories of history?

• disorder 

• treatment 

what is disorder?

– How and when did this start?
– What kind of symptoms were present when it started?
– Did any of the symptoms spread anywhere else?
– What were you doing around the time of the onset?
– What do you think happened?
– Why do you think you hurt?
– Describe how (if any) the original symptoms have progressed over time.
– Since this initially started, is it getting better, worse, or staying the same?

what is treatment?

• What medical tests were done?
• Which providers have they seen?
• Medications prescribed and its effect?
• Current treatments, co-current treatment?

what is site of symtpoms?

• pain location matter

• body charts help patients visually communicate pain areas 

• body charts are valuable because they: 

  • – Empower patients to express their pain

  • – May reveal neuroplastic changes (e.g., central sensitization, neglect)

  • – Help differentiate between peripheral and central pain mechanisms

Patient Example – R Knee Pain

what is Behavior of Symptoms?

• helps establish 

• symptom response 

• locus of control

what is helps establish?

– Diagnosis
– Pain mechanisms
– Precautions
– Contraindications
– Planning physical exam
– Treatment

what is symptom response?

– What increases symptoms?
– Decreases?

what is locus of control?

• – What can you do for me?

  • Favors passive treatment techniques

• what can i do for myself?

  • Favors active treatment techniques

what is Symptom Irritability?

• hyperalgesia 

• allodynia

• take away

what is hyperalgesia?

Increased pain from a stimulus that normally provokes pain

what is allodynia?

Pain due to a stimulus that does not normally provoke pain

what is take away?

More irritable the condition, the less vigorous the tests and treatments should be.

what is Special Questions?

• reviews the medical intake forms, and reviews systems, medical reports, or charts

• aligned with a risk factor, precaution, or contraindication 

• ask additional questions to explore this further to determine if this needs further examination or referral to the doctor 

Subjective Info By Mechanism

Step 3 - Physical Exam

what is categories of Physical Exam?

• planning the exam

• conducting the exam 

what is planning the exam ?

– What pain mechanism is dominant?
– What tests are definitely needed for today?
– Neurological evaluation needed?
– Safety tests
– Irritability level which may influence the number and vigor of tests

what is conducting the exam?

– Helps confirm the subjective hypothesis/diagnosis
– Establish a baseline of impairment
– Drive treatment choice
– Establish safety
– Patient expectations
– Create healing environment

• Pain with loading; relief with unloading (“on-off ” response)
• Pain matches complaint; typically sharp, dull, or intermittent
• End-range loading (e.g., over-pressure) is safe and useful
• Special tests
• Neuro screen needed to rule out nerve involvement
• Check strength, sensation, reflexes across relevant dermatomes/myotomes

Physical Exam - Nociceptive Dominant

what is Physical Exam - Peripheral Neuropathic?

• neuro screen 

• mechanosensitivity

what is neuro screen?

sensation, strength, reflexes in dermatomes/cutaneous fields

what is mechanosensitivity?

• nerve palpation 

• pressure algometry 

• neurodynamic tests 

  • ULTT Median, Radial, Ulnar

  • SLR, Slump

what is Functional movement examination?

– Functional strength vs MMT
– Large functional movements
– Transfers, mobility
– Balance
– TUG or 1 minute sit/stand
– Limit Special Tests

what is Altered plasticity?

Laterality, 2-point discrimination, localization, graphesthesia

Thorough neuro screen

– Sensation
– Motor
– Reflex

what is sensitized nervous system?

– Neuro dynamics
• Active >Passive
– Nerve Palpation/PPT
• Local
• Remoteerality

• Laterality tasks involve identifying the correct side of the body (left or right) when shown images of body parts

• Performance on these tasks reflects the health of cortical body maps.

Laterality (Left/Right Judgement)

what is normative data of laterality?

– Hands and Feet:
• Accuracy: >80%
• Speed: 1.5–2.5 seconds per image
– Spine (neck/back movement direction):
• Accuracy: ~80%
• Speed: 1.1–2.1 seconds per image

what is 2 Point Discrimination?

• ability to distinguish two closely spaced points touching the skin as separate

• Tactile acuity is often impaired in individuals experiencing pain

• helps assess the integrity of the body’s sensory map

what is Localization?

• the ability to accurately identify where on the body a tactile stimulus is applied

• 9-block or 12-block grid

• Stimulate areas using a pencil eraser after instruction

• Stimulate 20 areas and calculate percentage correct to assess accuracy

  • – 80% is suggested

Purpose:
To evaluate tactile localization accuracy and cortical sensory mapping in patients with low back pain.

Procedure:
1.Prepare the Grid:
Draw or place a 3x3 grid (9 blocks) over the lumbar region of the patient's back.
Ensure the grid is evenly spaced and covers the area of reported symptoms.
2.Instructions to Patient:
Inform the patient that you will lightly touch different areas within the grid and
they should identify the location of each stimulus.
3.Stimulus Application:
Use a pencil eraser or similar blunt object to gently touch one block at a time.
Randomize the order of stimulation to avoid pattern recognition.
4.Patient Response:
After each touch, ask the patient to point to or verbally identify the location
they felt the stimulus.
5.Scoring:
Record the number of correct responses out of 20. A score of ≥80% accuracy is
considered normal. Lower scores may indicate altered sensory processing or
central sensitization

9-Grid Localization for Low Back Assessment

what is Graphesthesia?

• Ability to recognize writing on the skin purely by the sensation of touch

• Helps assess sensory perception and cortical processing

  • somatosensory cortex

what is Graphesthesia procedure?

– clinician may trace a number or letter on a patient's palm or back using a blunt object (like the eraser end of a pencil)
– Without looking the patient must identify what was written

• Pair Up

• – Students form pairs (A and B).

• Testing Phase (10 min):
  – Student A closes eyes
  – Student B uses a blunt object to trace a number or letter (A–Z, 0–9) on Student A’s palm
  – Student A verbally identifies what was traced.
  – Repeat 5–6 times, then switch roles

Graphesthesia Activity

• Choose functional outcome measures that align closely with the primary concern
• evidence supports focusing on function rather than pain in treatment
– function tends to improve even when pain persists
• ultimate goal of PT is improved function despite ongoing pain.

Functional Outcome Measures

• Oswestry Disability Index (ODI)
• Neck Disability Index (NDI)
• Roland-Morris Disability Questionnaire (RMDQ)
• Lower Extremity Functional Scale (LEFS)
• Disabilities of the Arm, Shoulder, and Hand (DASH)

• Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)
• Global Rating of Change (GROC)
• Patient Specific Functional Scale (PSFS)

Examples of Patient Reported Functional Outcome Measures

Step 4 Treatment – Overview

• Traditional treatments
  – Mobilization
  – Manipulation
  – Exercise
  – Etc.

• Overpressure

• Sustained, combined and repeated movement

• High fear or pain catastrophizing: PNE

Treatment - Nociceptive Dominant

• Commonly seen in therapy, i.e., radiculopathy

• Traditional treatments – mobilization and manipulation
  – Careful with overpressure
  – Watch for latency

• Neurodynamics:
  – Sliders and Tensioners
  – Space, movement and blood flow
  – Pain neuroscience education
  – Graded motor imagery

Treatment - Peripheral Neuropathic

what is neurodynamics?

– Sliders and Tensioners
– Space, movement and blood flow
– Pain neuroscience education
– Graded motor imagery

• cognitive therapy

• movement 

• calming the nervous system

Treatment – Nociplastic Dominant

what is under movement?

education, goal setting, pacing, and graded exposure

what is under calming the nervous system?

on-pharmacological alternatives such as mindfulness, meditation, sleep hygiene, and biofeedback