PT Assessment of Pain

Professional Credentials and Introduction

• Presenter: Bryan Cheddar, PT, DPT, CMPT, OCS, FAAOMPT.

  • Certified Manual Physical Therapist.

  • Board Certified Specialist in Orthopaedic Physical Therapy.

  • Fellow, American Academy of Orthopaedic Manual Physical Therapy.

• Topic: Physical Therapist Assessment of Pain.

Patient Needs, Safety, and Screening

• Patient Expectations and Desires: Based on available body of evidence, a patient experiencing pain expects the following from their healthcare provider:

  • A thorough physical examination.

  • A clear and concise diagnosis.

  • Comprehensive education regarding his or her specific problem.

  • Information concerning the prognosis and the Plan of Care (POC).

  • A Detailed explanation of the prescription (Rx) and POC.

  • Personalized and individualized care.

  • Reductions in pain accompanied by improved functional capabilities.

• Safety and Screening Protocols:

  • Red Flag Screening is CRUCIAL: Practitioners must not be too quick to attribute unusual symptoms solely to a complex pain state without ruling out serious pathology.

  • Non-Musculoskeletal (Non-MSK) Referral Patterns: It is essential to maintain a healthy working knowledge of referral patterns for non-MSK issues.

  • Assumption Warning: Never assume that thorough screening has already been performed by another provider.

Subjective Exam (SE) Considerations: Communication and Alliance

• Therapeutic Alliance (TA): The Subjective Exam is the most important part of the examination. Beyond clinical information, it is the primary tool for establishing TA, which is especially critical when working with patients suffering from persistent or complex pain.

• Verbal Communication Strategies:

  • Words that Harm: Certain terms and phrases commonly used by healthcare professionals (HCPs) can be more harmful than helpful.

  • Pain Rating Caution: Avoid repeatedly asking for a "pain rating" in patients with chronic or complex pain, as this can be detrimental.

  • Validation Techniques: Rephrase or summarize information gathered from the patient to convey active listening.

  • Positive Reinforcement: Provide frequent reassurance and strive to communicate "the good news" discovered during the exam.

• Non-Verbal Communication:

  • Patient Cues: Observe the patient for facial expressions, sympathetic nervous system responses, holding or guarding of body parts, unloading, or signs of neglect.

  • Provider Cues: Be aware of your own non-verbals. Limit computer use to maintain eye contact, sit level with or below the patient, confirm findings with appropriate touch, maintain an open posture, and nod to show understanding.

• Interaction Style:

  • Focus on open-ended questions to "peel back the layers" of complex pain presentations.

  • Use closed-ended (yes/no) questions only for clarification or confirmation.

  • Speech Rate: Speak slowly; patients with persistent pain may have difficulty with focus and concentration. Allow them time to process info.

Subjective Exam: History and Body Chart

• Detailed History Gathering: It is vital to determine the history of onset, progression, and prior treatments.

  • Key Questions for the Patient:

    • How and when did this start?

    • What kind of symptoms were present at the start?

    • Did symptoms spread to other areas?

    • What were you doing around the time of the onset?

    • What do you think happened?

    • Why do you think you hurt?

    • Describe how the original symptoms have progressed (if at all) over time.

    • Is it getting better, worse, or staying the same?

• Tests and Prior Treatments: Knowing past and current interventions provides insight into patient beliefs and expectations.

  • Medical Tests: What tests were done? Why? What were the results, and what does the patient think about those results?

  • Providers: Which providers have they seen? What treatments were provided, and what was the patient told? What was helpful versus not helpful?

  • Medications: Identify medications taken and their effects. This includes controlled substances, over-the-counter (OTC) treatments, and non-pharmaceuticals (creams, gels, etc.).

• The Body Chart (BC):

  • Crucial for both simple and complex pain cases.

  • Provides early clues for diagnosis and the dominant pain mechanism.

  • While PT-completed charts are typically preferred, having the patient complete it can offer insight if they are given enough time and instruction.

  • Can reveal signs of neglect, central sensitization (CS), or changes in cortical representations.

  • Used to assess and convey progress over time.

  • Must include data on depth, frequency, and description of symptoms.

Subjective Exam: Symptom Behavior and Mechanisms

• Aggravating and Easing Factors:

  • Increases (Aggravating): Explore mechanical triggers and psychosocial variables that impact symptoms.

  • Decreases (Easing): Classify by Locus of Control.

    • External Locus: Something done to the patient (e.g., surgery, injections, manual therapy, dry needling, medication).

    • Internal Locus: Something done by the patient (e.g., exercise, mindfulness, breathing exercises).

  • This data helps estimate irritability to plan the Objective Exam (OE).

• Subjective Data for Specific Pain Mechanisms:

  • Nociceptive Mechanism:

    • Clear aggravating/easing factors related to loading/strain.

    • Descriptors: Intermittent, sharp, ache, or throb.

    • Absence of neurological symptoms (numbness, pins/needles).

  • Peripheral Neuropathic Mechanism:

    • Pain follows dermatome or cutaneous referral patterns.

    • Presence of neurological symptoms (numbness, pins/needles).

    • Aggravating/easing maneuvers may mimic neurodynamic test positions.

  • Central Mechanisms (Nociplastic):

    • Multiple and inconsistent aggravating factors.

    • Small movements cause significant pain; symptoms may be latent.

    • Widespread pain distribution.

    • Associated with psychosocial issues: Fear/fear-avoidance, pain catastrophizing, and depression.

Planning and Principles of the Objective Exam (OE)

• Planning Questions:

  • What is the dominant pain mechanism?

  • If nociceptive/peripheral neuropathic, what structures drive the pain?

  • What are the priority tests? Which can be deferred?

  • Is a neuro exam or safety/screening test required?

  • How must the exam be modified based on Irritability and Stability?

• Key Handling Principles:

  • Ask permission to touch.

  • Be thoughtful with word choices describing tests.

  • Demonstrate on the uninvolved side first.

  • Empower the patient to report all information; avoid "leading the witness."

  • Observe movement quality and the relationship between movement and pain.

  • Let the patient perform tests actively before passively when possible.

• Pain Mechanism Influences on Results:

  • Nociceptive-dominant: Pain provocation (e.g., raising a left leg) is specific to the affected area and not provoked elsewhere (e.g., the right leg).

  • Central Sensitization: Provocation in the affected area likely also provokes symptoms in remote areas (e.g., opposite limb), indicating widespread mechanosensitivity.

Objective Evaluation: Nociceptive and Neuropathic Identification

• Traditional OE Focus:

  • Identify "on switches" and "off switches."

  • Assess comparability and check against baselines.

  • Neuro exams used to r/o peripheral neuropathic involvement or distinguish between referred and neuropathic pain.

• Recognition of Tissue Involvement:

  • Contractile (Muscle, Tendon, Fascia): Pain with Active ROM, Resistance, and Passive elongation/stretch.

  • Inert (Joint, Cartilage, Bursa, Disc): Pain with End-range compression using AROM/PROM and Loading/Weightbearing.

  • Inert (Capsule, Ligament): Pain with End-range tension using AROM/PROM and Ligamentous stress tests.

  • Nervous Tissue: Pain with Passive elongation/neural tension; verified with Sensory, Motor, and Reflex testing.

Clinical Finding Interpretations

Objective Evaluation in Sensitized People

• Mechanosensitivity Tests:

  • Palpation: While poor for reliability in asymmetry/movement disorders, it is highly reliable for pain provocation.

  • Pressure Pain Threshold (PPT): Uses a pressure algometer applied at a rate of approximately $1\,kg/s$. The patient says "Stop" when pressure becomes pain. Take the average of the 2nd and 3rd measures (out of 3).

    • MCID: $15\%$.

  • Neurodynamic Testing: Use active variations before passive. Apply the "Order of Movement Principle."

    • Nociceptive/Peripheral: Provokes symptoms locally in the affected region.

    • Central/Nociplastic: Sensitive in multiple tests; provokes symptoms in remote areas.

• Confirmation of Central Sensitization (CS) (per Jo Nijs):

  • Sensitivity to touch, heat, cold, or vibration at remote sites.

  • Vibration: Using a $256\,Hz$ tuning fork over superficial nerves.

  • End-feels: Expect an "empty" end-feel (P2 before R2) or guarding/spasm (S2) due to allodynia/hyperalgesia.

  • Thermal: Heat and cold tolerated for shorter durations or interpreted as pain.

• PPT Before and After Exercise:

  • Aerobic exercise (intensity $70\%-80\%$ or Zone 3) triggers endogenous opioid release to reduce pain.

  • For centrally sensitized patients, lower intensity ($50\%-60\%$ or Zone 1) is ideal.

  • Karvonen Formula: $\text{Target HR} = (\%\text{Intensity} \times \text{HRR}) + \text{RHR}$, where $\text{HRR} = \text{HR}_{max} - \text{RHR}$.

  • Normal Response: PPT should increase after exercise. In Nociplastic pain, this endogenous mechanism is often lacking.

Rate of Perceived Exertion (RPE) and Heart Rate Scale

Neuroplasticity Tests in Central/Nociplastic Pain

Neuroplastic changes occur due to immune responses in the dorsal horn and structural brain changes.

• Laterality (Left/Right Judgement): Difficulty distinguishing left vs. right body parts, even when looking at images.

  • Hands/Feet Norms: $80\%$ accuracy; speed of $1.5 - 2.5\,s$.

  • Spine Norms: $80\%$ accuracy; speed of $1.1 - 2.1\,s$.

• 2-point Discrimination (TPD): The ability to discern two distinct points of contact on the skin versus one. Often distorted in nociplastic pain.

• Localization: Ability to determine the specific location being touched.

  • Method: Patient is oriented to a grid. Touched $20\times$ in random squares.

  • Reference point: Accuracy of $80\%$.

Screening Tools and Outcome Measures

• Pain Scales: NPRS, VAS, Wong-Baker Faces, Magill Pain Questionnaire.

• Knowledge Assessment: Neurophysiology of Pain Questionnaire (NPQ) helps target Pain Neuroscience Education (PNE).

• Pain Classification: Central Sensitization Inventory (CSI).

• Functional Outcome Measures: ODI (Oswestry Disability Index), NDI (Neck Disability Index), GROC (Global Rating of Change), PSFS (Patient-Specific Functional Scale).

• Psychosocial Assessment:

  • FABQ (Fear-Avoidance Beliefs Questionnaire).

  • TSK (Tampa Scale of Kinesiophobia).

  • PCS (Pain Catastrophizing Scale).

  • Depression Screening: 3-item quick screen or PHQ9.

  • OSPRO-YF (Optimal Screening for Prediction of Referral and Outcome Yellow Flag).